How should I manage atopic dermatitis and the resulting post‑inflammatory scarring?

Management of Eczema and Post-Inflammatory Scarring

For active eczema, apply moderate-to-potent topical corticosteroids (such as mometasone furoate or clobetasol propionate 0.05%) twice daily to all affected areas until clearance is achieved, then transition to twice-weekly proactive maintenance on previously involved skin to prevent relapses and minimize scarring. 1, 2

Foundation: Daily Emollient Therapy

Emollient therapy is the cornerstone of eczema management and must be maintained regardless of disease activity or severity. 1, 2

• Apply fragrance-free emollients liberally throughout the day, immediately after bathing (within 10-15 minutes) to damp skin to create a surface lipid film that reduces transepidermal water loss and restores barrier function. 1, 2, 3
• Use ointments or thick creams rather than lotions for maximum occlusion and penetration, especially for lichenified or chronic lesions. 4
• Substitute all regular soaps with soap-free cleansers, as soaps strip natural lipids and worsen barrier dysfunction. 2, 4
• Continue aggressive emollient use even during clear periods—this provides documented steroid-sparing effects and extends recurrence-free intervals. 1, 4, 3
• Expect to use 200-400 grams per week when applying twice daily to affected areas in adults. 4

Active Flare Management: Topical Corticosteroids

The potency and duration of topical corticosteroid use should be matched to the severity and location of disease, always using the lowest potency that achieves control. 1, 2

Application Strategy

• Apply moderate-to-potent corticosteroids (e.g., mometasone furoate, fluticasone propionate, or clobetasol propionate 0.05%) no more than twice daily to active lesions until significant improvement occurs, typically 2-4 weeks. 1, 5, 2
• For facial or periorbital eczema, use only hydrocortisone 1-2.5% because facial skin is uniquely thin and prone to corticosteroid-induced atrophy and telangiectasia. 2
• Avoid very potent corticosteroids on the face, neck, skin folds, and genitals where atrophy risk is highest. 1, 2

Proactive Maintenance to Prevent Scarring

After achieving clearance, switch to proactive maintenance therapy: apply the same corticosteroid twice weekly (e.g., weekend therapy) to previously affected skin areas for up to 16 weeks. 1, 5, 2 This approach:

• Prevents disease relapses and the repeated inflammation that leads to post-inflammatory hyperpigmentation and scarring. 1
• Has been validated in children with moderate-to-severe atopic dermatitis using low-to-medium potency agents. 1
• Should incorporate short "steroid holidays" when feasible to minimize adverse effects. 5, 2

Alternative Topical Anti-Inflammatory Agents

Topical calcineurin inhibitors (tacrolimus 0.03-0.1% ointment or pimecrolimus 1% cream) are steroid-sparing options for patients aged 2 years and above, particularly useful for facial eczema and proactive maintenance. 1, 2, 6

• Apply 2-3 times per week to previously involved sites as maintenance therapy when corticosteroid-related concerns exist. 2
• These agents do not cause skin atrophy and are therefore preferred for long-term use on sensitive areas. 1, 6

Managing Secondary Bacterial Infection

Crusting, weeping, purulent exudate, or pustules indicate secondary bacterial infection with Staphylococcus aureus—the most common complication that can worsen scarring. 2, 4

• Prescribe oral flucloxacillin as first-line antibiotic (or erythromycin for penicillin allergy). 2, 4
• Do not discontinue topical corticosteroids when infection is present—continue them concurrently with appropriate systemic antibiotics. 2, 4
• If β-hemolytic streptococci are isolated, switch to phenoxymethylpenicillin. 2
• Obtain bacterial cultures when the skin fails to improve after initial antibiotic treatment. 2

Eczema Herpeticum: Medical Emergency

Grouped vesicles, punched-out erosions, or sudden deterioration with fever suggest eczema herpeticum—initiate oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients. 2

Adjunctive Measures to Minimize Trauma and Scarring

• Keep fingernails short to limit skin trauma from scratching and break the itch-scratch cycle. 2
• Choose smooth cotton clothing and avoid irritant fabrics such as wool. 2
• Maintain a cool ambient temperature and prevent excessive sweating. 2

Managing Pruritus

Sedating antihistamines (hydroxyzine, diphenhydramine) may improve nighttime itching through their sedative effect, not through direct antipruritic action. 2

• Use exclusively at bedtime for severe itching that disrupts sleep. 2, 4
• Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be prescribed. 2
• Antihistamines must not replace topical anti-inflammatory therapy. 2

Post-Inflammatory Hyperpigmentation and Scarring

The best strategy to prevent post-inflammatory scarring is aggressive control of active inflammation through proactive maintenance therapy with twice-weekly topical corticosteroids after clearance. 1, 5, 2

While the provided evidence does not address specific treatments for established post-inflammatory hyperpigmentation in eczema, preventing repeated flares through proactive maintenance is the most effective approach to minimize scarring. 1, 3

Second-Line Therapies for Moderate-to-Severe Disease

Wet-Wrap Therapy

Wet-wrap therapy with topical corticosteroids is an effective short-term second-line treatment for moderate-to-very severe eczema failing conventional topical therapy. 1

• Recommended duration is 3-7 days, with possible extension to 14 days in severe cases. 1
• Promotes trans-epidermal penetration of corticosteroids and serves as a barrier against scratching. 1

Phototherapy

Narrowband UVB (312 nm) is a safe and effective option for moderate-to-severe disease when topical therapy is insufficient. 1, 2

• Should be considered only after failure of appropriately potent topical corticosteroids, adequate treatment duration, and consistent emollient use. 2
• Long-term risks include premature skin aging and potential increase in cutaneous malignancies, particularly with PUVA. 1, 2

Systemic Immunosuppressants

Systemic therapy is indicated when optimized topical therapy fails to produce adequate response after 4 weeks of appropriate use. 5

• Cyclosporine (3-6 mg/kg/day): Effective for refractory disease; monitor serum creatinine and reduce dose by 1 mg/kg/day if it rises >25% above baseline. 5
• Methotrexate (7.5-25 mg once weekly): Requires concurrent folate supplementation; reduce dose if transaminases exceed 3× upper limit of normal. 5
• Azathioprine (1-3 mg/kg/day): Dose guided by TPMT enzyme activity; requires baseline tuberculosis screening. 5
• Oral corticosteroids should be reserved exclusively for acute severe exacerbations as a short-term bridge to steroid-sparing agents—never for maintenance therapy. 5, 2

Referral and Escalation Criteria

Refer to dermatology or escalate care when: 2

• No response to moderate-to-potent topical corticosteroids after 4 weeks of appropriate use
• Systemic therapy or phototherapy is contemplated
• Eczema herpeticum is suspected (urgent referral)
• Diagnostic uncertainty or atypical presentation exists

Common Pitfalls to Avoid

• Do not delay topical corticosteroids due to "steroid phobia"—undertreatment leads to chronic inflammation and increased scarring risk. 2
• Do not use very potent corticosteroids continuously without breaks—implement twice-weekly maintenance dosing after clearance instead of daily application. 1, 5, 2
• Do not withhold topical corticosteroids when bacterial infection is present—they remain the primary treatment when appropriate antibiotics are given concurrently. 2, 4
• Do not prescribe non-sedating antihistamines for eczema—they have no demonstrated benefit. 2
• Do not use oral corticosteroids for long-term maintenance—high morbidity in chronic use, especially in older adults. 5, 2