Treatment of Eczema (Atopic Dermatitis)
Apply topical corticosteroids twice daily as first-line therapy, using the least potent preparation that controls symptoms, combined with liberal emollient use as the cornerstone of maintenance therapy. 1
First-Line Topical Corticosteroid Strategy
Start with low-to-moderate potency topical corticosteroids applied no more than twice daily to affected areas. 1 For facial or thin-skinned areas (neck, flexures, genitals), use only hydrocortisone 1–2.5% to minimize atrophy risk. 1, 2
For body and extremity lesions, use moderate-to-potent corticosteroids (e.g., mometasone furoate, clobetasol propionate 0.05%) once or twice daily for 1–4 weeks to gain initial control. 3, 1 Select ointments for very dry skin, creams for daily non-greasy use, and lotions for hairy areas. 1
After achieving clearance (typically 2–4 weeks), transition to proactive maintenance: apply the same corticosteroid twice weekly to previously involved skin to prevent flares. 1 This approach extends remission and reduces overall steroid burden compared to reactive treatment. 1
Implement "steroid holidays"—short breaks from corticosteroid application—when feasible to reduce adverse effects including skin atrophy and pituitary-adrenal suppression. 3, 1, 2
Essential Emollient Therapy
Apply fragrance-free emollients liberally and frequently, especially immediately after bathing (within 10–15 minutes on damp skin), to create a surface lipid film that prevents transepidermal water loss. 1 Continue aggressive emollient use even during clear periods; this provides steroid-sparing benefits and prolongs time to flare from 30 to 180 days. 4
Substitute regular soaps with soap-free cleansers or dispersible creams, as soaps strip natural lipids and worsen barrier dysfunction. 1, 2
Encourage daily bathing for cleansing and hydration, followed immediately by emollient application. 1
Managing Secondary Bacterial Infection
Watch for crusting, weeping, purulent exudate, or pustules—these indicate secondary Staphylococcus aureus infection, the most common pathogen. 1, 4, 2
Prescribe oral flucloxacillin as first-line antibiotic; use erythromycin for penicillin allergy or suspected resistance. 1, 4, 2 If β-hemolytic streptococci are isolated, switch to phenoxymethylpenicillin. 1
Do not discontinue topical corticosteroids when infection is present—continue them concurrently with appropriate systemic antibiotics. 1, 4, 2 Infection is not a contraindication to topical steroid use. 1
If you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever, suspect eczema herpeticum—this is a medical emergency. 1, 2 Initiate oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients. 1
Alternative Topical Anti-Inflammatory Agents
Topical calcineurin inhibitors (pimecrolimus 1% cream or tacrolimus ointment) can be used 2–3 times weekly as proactive maintenance after disease stabilization, particularly when steroid-related concerns exist. 3, 1 These agents are FDA-approved for patients aged 2 years and older with atopic dermatitis not adequately controlled by topical therapies. 5
Use pimecrolimus or tacrolimus only on areas with active eczema, for short periods with breaks in between; stop when symptoms resolve. 5 The most common side effect is burning or warmth at application sites, typically mild and resolving within days. 5
Managing Pruritus
Sedating antihistamines (hydroxyzine, diphenhydramine) may help nighttime itching through their sedative properties, not direct antipruritic effects—reserve for nighttime use during severe flares only. 1, 2
Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be prescribed routinely. 1
Systemic Therapy for Moderate-to-Severe Disease
Dupilumab (IL-4/IL-13 inhibitor) is FDA-approved for moderate-to-severe atopic dermatitis in patients aged 6 months and older whose disease is not adequately controlled with topical therapies. 6 It can be used with or without topical corticosteroids. 6 Dosing: adults receive 600 mg loading dose (two 300 mg injections at different sites), then 300 mg every 2 weeks subcutaneously. 6
Reserve systemic immunosuppressants (cyclosporine 2.5–5 mg/kg/day, methotrexate 7.5–25 mg/week, azathioprine 1–3 mg/kg/day) for severe, recalcitrant disease that has failed adequate topical therapy. 3, 1 Cyclosporine showed 73% reduction in severity scores but requires monitoring for renal insufficiency, hypertension, and drug interactions. 3
Narrowband UVB phototherapy (312 nm) is an option for moderate-to-severe disease when first-line treatments fail, though concern exists about long-term adverse effects including premature skin aging and cutaneous malignancies. 1
Systemic corticosteroids have a limited role only for acute severe flares requiring rapid control when topical therapy has failed—use short-term to "tide over" during crisis periods, never for maintenance. 1 Pituitary-adrenal suppression and corticosteroid-related mortality are significant risks with prolonged use. 1
Critical Pitfalls to Avoid
Do not undertreat due to steroid phobia—explain that appropriate short-term use of potent steroids is safer than chronic undertreated inflammation. 4, 2 Patients' or parents' fears often lead to inadequate disease control. 3
Avoid very potent corticosteroids on thin-skinned areas (face, neck, flexures, genitals) where atrophy risk is highest. 1
Do not use topical corticosteroids continuously without breaks—implement steroid holidays when possible. 1
Do not delay or withhold topical corticosteroids when infection is present—they remain primary treatment when appropriate systemic antibiotics are given concurrently. 1, 2