What treatment should I prescribe for an adult with an acute eczema flare and no known contraindications?

Treatment for Acute Eczema Flare in Adults

For an adult experiencing an acute eczema flare, prescribe a medium-potency topical corticosteroid (such as mometasone furoate 0.1% ointment or cream) applied twice daily to affected areas, combined with liberal application of fragrance-free emollients to the entire body at least once daily. 1, 2

Initial Treatment Regimen

Topical Corticosteroid Selection

• Medium-potency corticosteroids (e.g., mometasone furoate 0.1%, fluticasone propionate 0.05%, or prednicarbate 0.02%) are the appropriate first-line choice for most body areas in moderate-to-severe flares 1, 2
• Apply twice daily to all affected areas until the flare is controlled, typically 2-4 weeks 1, 3, 4
• For facial or intertriginous areas, use low-potency agents (hydrocortisone 1% or alclometasone dipropionate 0.05%) to minimize atrophy risk 1, 2
• Potent corticosteroids (e.g., betamethasone dipropionate) may be considered for severe flares on the trunk and extremities, but limit use to 2 consecutive weeks 1, 3, 4

Essential Adjunctive Therapy

• Emollients are non-negotiable: Apply fragrance-free moisturizers to the entire body (not just affected areas) at least once daily, ideally immediately after bathing 1, 2, 5
• Use urea- or glycerin-based moisturizers for enhanced barrier restoration 1, 2
• Recommend soap-free cleansers and avoid hot showers to prevent further barrier disruption 1, 2

Assessment for Secondary Infection

When to Add Antibiotics

• If the patient has broken skin, scabbing, oozing, or crusting, presume secondary bacterial infection (typically Staphylococcus aureus) 5
• Prescribe oral flucloxacillin as first-line antibiotic therapy; use erythromycin if penicillin allergy or flucloxacillin resistance 5
• Do NOT use topical antibiotic/steroid combinations for overt infection—oral antibiotics are preferred 5
• Be vigilant for eczema herpeticum (multiple discrete vesicles/erosions), which requires oral acyclovir, not antibiotics 5

Symptom Management

Pruritus Control

• Topical polidocanol cream or urea-containing lotions can soothe itching 1
• For severe pruritus, consider short-term use of sedating oral antihistamines (e.g., diphenhydramine, clemastine) at night only 1
• Avoid non-sedating antihistamines—they have little to no value in atopic eczema 5

Transition to Maintenance Therapy

After Flare Control (2-4 Weeks)

• Do NOT stop treatment when lesions appear cleared—this is the most common cause of rapid relapse 2
• Transition to proactive maintenance therapy: Apply the medium-potency corticosteroid twice weekly (e.g., Monday and Thursday) to all previously affected areas, even when skin appears normal 1, 2
• Continue this regimen for 16-36 weeks—this reduces relapse risk approximately 7-fold (from 58% to 25%) 1, 2
• Maintain daily emollient use throughout maintenance therapy 1, 2

If Symptoms Persist After 2 Weeks

• If burning or itching persists despite appropriate corticosteroid use, add topical tacrolimus 0.03% or 0.1% on non-steroid days (2-3 times weekly) 1, 2
• Consider contact dermatitis to topical agents and evaluate for patch testing if no improvement 2
• Reassess the diagnosis if no improvement after 2 weeks of appropriate therapy 3

Critical Safety Considerations

What NOT to Do

• Never continue high-potency or very potent corticosteroids beyond 2 consecutive weeks due to atrophy risk 1, 2, 3
• Never apply corticosteroids more than twice daily—once daily application of potent steroids is equally effective 1, 4
• Never use amounts exceeding 50g per week of super-high potency corticosteroids 3
• Never rely on emollients alone without scheduled anti-inflammatory therapy for recurrent disease 2
• Avoid oral antihistamines for routine itch control—minimal benefit beyond sedation 5

Monitoring Requirements

• Reassess after 2 weeks; if worsening or no improvement, consider referral to dermatology 1
• Monitor for steroid-related adverse effects (skin atrophy, telangiectasias, striae), especially on face, neck, and body folds 2
• For maintenance therapy beyond 36 weeks, transition to a tacrolimus-based proactive regimen to minimize long-term steroid exposure 2

Alternative Considerations for Chronic Disease

• Narrowband UVB phototherapy (TL-01) is effective for chronic atopic eczema when combined with topical steroids, with evidence of prolonged remission 1
• Topical calcineurin inhibitors (tacrolimus 0.03%/0.1% or pimecrolimus 1%) are appropriate steroid-sparing alternatives, particularly for facial involvement 1
• Newer agents such as crisaborole (PDE-4 inhibitor) or ruxolitinib cream (JAK inhibitor) are FDA-approved for mild-to-moderate disease 1