What is the recommended management for scalp eczema?

Management of Scalp Eczema

For scalp eczema (atopic dermatitis of the scalp), apply a moderate-to-potent topical corticosteroid solution or shampoo formulation twice daily for 2–4 weeks, combined with aggressive emollient use and soap-free cleansers, then transition to twice-weekly proactive maintenance dosing once clearance is achieved.

First-Line Topical Corticosteroid Strategy

• Use class 1–7 topical corticosteroids for a minimum of up to 4 weeks as initial treatment of scalp eczema 1
• Apply the corticosteroid no more than twice daily, selecting the lowest potency that achieves symptom control 2
• Solution or shampoo formulations are preferred for scalp application because they penetrate through hair, avoid greasy residue, and improve patient compliance compared to creams or ointments 3, 4
• Clobetasol propionate 0.05% solution is the most widely used high-potency option for scalp dermatoses, with 75.1% dermatologist agreement for effectiveness and broad action 4
• For milder disease or maintenance, moderate-potency options (class 3–5) such as triamcinolone acetonide solution can be used 1, 5

Proactive Maintenance After Clearance

• Once the scalp eczema clears (typically 2–4 weeks), apply the same topical corticosteroid twice weekly to previously involved scalp areas to prevent flares 2
• This proactive maintenance strategy significantly extends remission periods and reduces the need for continuous daily steroid use 2
• Implement short "steroid holidays" when feasible to minimize adverse effects such as skin atrophy, even though the scalp is relatively resistant to atrophy 1, 2

Essential Emollient and Scalp-Care Measures

• Apply emollients liberally to the scalp immediately after washing, even during clear periods, to restore barrier function and provide steroid-sparing benefits 2
• Use soap-free cleansers or medicated shampoos (such as ketoconazole or tar-based formulations) as soap substitutes because regular shampoos strip natural lipids and worsen barrier dysfunction 1, 2, 3
• Continue aggressive emollient use during remission; this provides long-term steroid-sparing benefits and extends recurrence-free intervals 2

Management of Secondary Bacterial Infection

• Monitor for increased crusting, weeping, purulent exudate, or pustules—these indicate secondary infection with Staphylococcus aureus 2
• When bacterial infection is confirmed, prescribe oral flucloxacillin (or erythromycin for penicillin allergy) while continuing topical corticosteroids concurrently—do not withhold steroids during appropriate antibiotic therapy 2
• Obtain bacterial cultures if the scalp does not improve after initial antibiotic treatment 2

Recognition of Eczema Herpeticum (Medical Emergency)

• If grouped vesicles, punched-out erosions, or sudden deterioration with fever develop, suspect eczema herpeticum and initiate oral acyclovir immediately 2
• In febrile or systemically ill patients, administer intravenous acyclovir 2
• This is a medical emergency requiring urgent evaluation 2

Alternative Topical Anti-Inflammatory Agents

• For patients with steroid-related concerns, topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus ointment) may be applied 2–3 times per week as proactive maintenance after disease stabilization 2, 6
• Pimecrolimus is FDA-approved for short-term and intermittent long-term therapy in patients ≥2 years old who have failed other treatments 6
• Do not use pimecrolimus continuously for long periods; apply only to areas with active eczema 6

Pruritus Management

• Sedating antihistamines (hydroxyzine, diphenhydramine) may improve nighttime itching through sedative effects, not direct antipruritic action 2
• Non-sedating antihistamines have no proven benefit in atopic eczema and should not be prescribed 2
• Use sedating antihistamines only intermittently at bedtime when itch disrupts sleep; they must not replace topical anti-inflammatory therapy 2

Common Pitfalls to Avoid

• Do not use cream or ointment formulations on the scalp—they are cosmetically unacceptable, difficult to apply through hair, and reduce compliance 3, 4
• Do not discontinue topical corticosteroids when bacterial infection is present—continue them with appropriate systemic antibiotics 2
• Avoid continuous daily use of potent corticosteroids beyond 4 weeks without implementing twice-weekly maintenance dosing 1, 2
• Do not use pimecrolimus in children under 2 years of age 6

Escalation and Referral Criteria

• Refer patients who do not respond to moderate-to-potent topical corticosteroids after 4 weeks of appropriate use 2
• Seek specialist management when systemic therapy (phototherapy, oral immunosuppressants, biologics) is contemplated 2
• Promptly refer for emergency evaluation if eczema herpeticum is suspected 2