What is the recommended management for chronic eczematous dermatitis?

Management of Chronic Eczematous Dermatitis

Liberal daily emollients combined with topical corticosteroids applied twice daily to active lesions form the foundation of chronic eczematous dermatitis management, with the least potent preparation that achieves control selected to minimize adverse effects. 1

First-Line Treatment Strategy

Daily Emollient Therapy (Cornerstone of Management)

• Apply emollients liberally and frequently throughout the day to maintain skin hydration and restore barrier function, even when the skin appears clear 1, 2
• Apply emollients immediately after bathing to damp skin to create a surface lipid film that prevents transepidermal water loss 1, 2
• Use soap-free cleansers or dispersible creams as soap substitutes because regular soaps strip natural lipids and worsen barrier dysfunction 1, 2
• Daily moisturizer use lengthens the time to first flare compared to no treatment 3

Topical Corticosteroid Application During Flares

• Apply topical corticosteroids no more than twice daily to affected areas using the least potent preparation that controls symptoms 1
• For facial involvement, use only low-potency preparations (hydrocortisone 1–2.5%) due to high risk of skin atrophy and telangiectasia on thin facial skin 1, 2
• For body and extremity lesions, moderate-to-potent corticosteroids (mometasone furoate, clobetasol propionate 0.05%) may be used during active flares 1
• Limit continuous use of potent or very potent corticosteroids to 2–4 weeks, then implement "steroid holidays" to minimize adverse effects 1

Proactive Maintenance to Prevent Flares

• After achieving clearance with daily topical corticosteroids, transition to twice-weekly application of the same corticosteroid to previously affected areas to reduce flare risk and extend remission periods 1
• Topical calcineurin inhibitors (tacrolimus 0.1% ointment for adults, 0.03% for children 2–15 years; pimecrolimus 1% cream) may be applied 2–3 times weekly as proactive maintenance when steroid-related concerns exist 3, 1, 4
• Continue aggressive emollient use during clear periods for long-term steroid-sparing benefits 1

Managing Secondary Bacterial Infection

• Monitor for increased crusting, weeping, purulent exudate, or pustules indicating Staphylococcus aureus superinfection 1
• Prescribe oral flucloxacillin as first-line antibiotic; use erythromycin for penicillin allergy 1
• Continue topical corticosteroids during bacterial infection when appropriate systemic antibiotics are given concurrently—do not delay or withhold anti-inflammatory therapy 1
• Obtain bacterial cultures if skin fails to improve after initial antibiotic treatment 1

Recognizing and Managing Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if grouped vesicles, punched-out erosions, or sudden deterioration with fever develop 1
• Initiate oral acyclovir immediately; administer intravenous acyclovir in febrile or systemically ill patients 1
• This is a medical emergency requiring urgent evaluation 1

Adjunctive Measures for Pruritus Control

• Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through sedative properties, not direct antipruritic effects 3, 1
• Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be routinely used 3, 1
• Short-term, intermittent use of sedating antihistamines is acceptable for sleep loss secondary to itch but should not substitute for topical therapy 3

Systemic Therapy for Moderate-to-Severe Disease

• Narrowband ultraviolet B (312 nm) phototherapy is an option when first-line topical treatments fail after 4 weeks of appropriate use 1
• Systemic immunosuppressants (cyclosporine 3–6 mg/kg/day, methotrexate 7.5–25 mg/week, azathioprine 1–3 mg/kg/day) are reserved for severe recalcitrant disease 3, 5, 6
• Oral corticosteroids have a limited role for short-term "tiding over" during acute severe flares after exhausting all other options, but should never be used for maintenance 1

Essential Supportive Measures

• Keep fingernails short to minimize skin trauma from scratching 1
• Choose cotton clothing and avoid irritant fabrics such as wool 1
• Maintain moderate ambient temperature and avoid excessive heat or sweating 1
• Avoid alcohol-containing products that worsen dryness 1

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia is common—educate patients that low-potency topical corticosteroids are safe when used correctly 1
• Do not use very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest 1
• Avoid continuous daily application of potent steroids without breaks—implement twice-weekly maintenance after clearance instead 1
• Do not prescribe non-sedating antihistamines routinely as they provide no benefit 3, 1

When to Refer or Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks of appropriate use 1
• Need for systemic therapy or phototherapy 1
• Suspected eczema herpeticum (medical emergency) 1
• Diagnostic uncertainty or atypical presentation 1, 2