Management of Eczema (Atopic Dermatitis)

First-Line Treatment: Topical Corticosteroids and Emollients

Topical corticosteroids are the mainstay of treatment for atopic eczema and should be applied no more than twice daily using the least potent preparation that achieves disease control. 1, 2

Topical Corticosteroid Application Strategy

Apply topical corticosteroids once or twice daily to affected areas only—more frequent application does not improve outcomes and increases adverse effects. 1, 2, 3
Use the lowest potency that controls symptoms: hydrocortisone 1–2.5% for face and thin-skinned areas (neck, flexures, genitals); moderate-to-potent preparations (mometasone, clobetasol) for body and extremities during flares. 1, 2, 4
Implement short "steroid holidays" when control is achieved—discontinue for brief intervals rather than continuous use to minimize skin atrophy and hypothalamic-pituitary-adrenal axis suppression. 1, 2
After achieving clearance (typically 2–4 weeks), transition to proactive maintenance: apply the same corticosteroid twice weekly to previously involved skin to prevent relapses. 2

Common pitfall: Steroid phobia leads to undertreatment in many patients. 1, 2 Explain clearly that appropriate short-term use of potent steroids is safer than chronic undertreated inflammation, and that different potencies carry different risk profiles. 1, 4

Essential Emollient Therapy

Liberal emollient use is the cornerstone of maintenance therapy and must be continued even when eczema appears controlled. 2, 5
Apply emollients immediately after bathing (within 10–15 minutes to damp skin) to create a surface lipid film that reduces transepidermal water loss. 1, 2
Prescribe sufficient quantities—adults require approximately 600 g/week for adequate coverage. 6
Not all emollients are equal: Urea-glycerol containing emollients strengthen the skin barrier and increase natural moisturizing factor levels more effectively than simple paraffin-based creams. 6
Replace soaps with soap-free cleansers or dispersible cream substitutes to preserve natural skin lipids. 1, 2

Managing Secondary Infections

Bacterial Infection (Most Common: Staphylococcus aureus)

Do not withhold topical corticosteroids when infection is present—continue them concurrently with appropriate systemic antibiotics. 2, 4

Suspect bacterial infection when you observe increased crusting, weeping, purulent exudate, or pustules. 1, 2
Start oral flucloxacillin as first-line antibiotic for S. aureus; use erythromycin for penicillin allergy or suspected resistance. 2, 4
Obtain bacterial cultures if the skin fails to improve after initial antibiotic treatment. 1, 2

Eczema Herpeticum (Medical Emergency)

Recognize grouped vesicles, punched-out erosions, or sudden deterioration with fever as eczema herpeticum—this requires urgent treatment. 1, 2
Initiate oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients. 2, 3
Send swabs for virological screening and electron microscopy to confirm herpes simplex infection. 1, 2

Managing Pruritus

Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through their sedative properties, not direct antipruritic effects—use short-term and intermittently. 2, 3
Non-sedating antihistamines have no value in atopic eczema and should not be prescribed. 2, 3

Systemic Therapy for Moderate-to-Severe Disease

When to Escalate

Refer or escalate when eczema fails to respond to moderate-to-potent topical corticosteroids after 4 weeks of appropriate use with consistent emollient therapy. 2

Preferred Systemic Agents (in order of recommendation)

Avoid systemic corticosteroids for chronic management—they cause rebound flares, HPA axis suppression, and should only be used as a 1–2 week bridge to steroid-sparing agents during acute severe exacerbations. 3

First-Line Systemic Options:

Dupilumab (biologic, IL-4/IL-13 inhibitor): First-line systemic agent with superior safety profile, no routine laboratory monitoring required. 4, 3, 7
JAK inhibitors (abrocitinib, upadacitinib, baricitinib): Strongly recommended but require monitoring of CBC, liver enzymes, and lipids; package labeling suggests use after failure of other systemic agents including biologics. 3, 7
Cyclosporine: First-line traditional immunosuppressant, dose 2.5–5 mg/kg/day divided twice daily; most evidence-based but limit to ≤12 months due to renal toxicity risk; monitor CBC, CMP, magnesium, uric acid, lipids, and blood pressure. 3, 7

Second-Line Traditional Immunosuppressants:

Methotrexate: 7.5–25 mg/week (adults), 0.2–0.7 mg/kg/week (children); requires folate supplementation and hepatic monitoring. 3
Azathioprine: 1–3 mg/kg/day (adults), 1–4 mg/kg/day (children); requires TPMT enzyme testing before initiation and CBC monitoring. 3
Mycophenolate mofetil: 1.0–1.5 g twice daily (adults), 30–50 mg/kg/day (children); less robust trial evidence. 3

Phototherapy

Narrowband UVB (312 nm) should be considered before systemic immunosuppressants when available, but only after failure of adequately potent topical corticosteroids and consistent emollient use. 2, 7
PUVA carries long-term risks of premature skin aging and cutaneous malignancies. 2

Adjunctive Measures to Prevent Flares

Keep nails short to reduce skin trauma from scratching. 1, 2
Wear smooth cotton clothing and avoid irritant fabrics such as wool. 1, 2
Maintain moderate ambient temperature and avoid extremes of heat or cold. 1, 2
Identify and avoid specific aggravating factors through careful history (irritants, allergens). 1

Special Considerations for Pediatric Patients

Children aged 0–6 years are more vulnerable to HPA axis suppression due to high body surface area-to-volume ratio—use low-potency corticosteroids (hydrocortisone 1%) for mild disease and limit high-potency agents to short courses (3–7 days) for severe flares. 3
Topical calcineurin inhibitors (tacrolimus 0.03% ointment, pimecrolimus 1% cream) are effective steroid-sparing alternatives for sensitive areas (face, genitals) and can be used 2–3 times weekly for proactive maintenance. 2, 3
Systemic corticosteroids carry heightened risk of growth impairment in children and must be avoided for chronic use. 3

Critical Pitfalls to Avoid

Do not delay topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 2, 4
Do not use very potent corticosteroids on face, neck, or flexures—risk of atrophy is markedly higher in thin-skinned areas. 2, 3
Do not prescribe systemic corticosteroids for maintenance—they create dependence, rebound flares, and serious long-term complications. 3
Do not use non-sedating antihistamines—they have no proven benefit in atopic dermatitis. 2, 3

What is the recommended management for eczema, including topical, systemic, and biologic therapies?

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