What is the appropriate treatment for a 51‑year‑old female with acute eczematous dermatitis presenting as erythematous papules on the extensor surfaces over dry skin with erosions from constant scratching?

Treatment for Acute Eczematous Dermatitis with Erosions

This patient requires high-potency topical corticosteroids (betamethasone valerate or clobetasol propionate) applied 1-3 times daily to the affected areas, combined with oral antihistamines (cetirizine 10 mg daily or hydroxyzine 10-25 mg QID) for pruritus control, plus aggressive emollient therapy applied at least once daily to the entire body. 1, 2

Topical Corticosteroid Selection and Application

• Use high-potency (Class I) topical corticosteroids such as clobetasol propionate, halobetasol propionate, or betamethasone valerate cream or ointment for body surfaces with acute eczematous lesions 1

• Apply a thin film to affected areas 1-3 times daily initially, though once or twice daily application is often equally effective for potent corticosteroids 2, 3

• Potent topical corticosteroids are significantly more effective than mild preparations for moderate to severe eczema, with treatment success rates of 70% versus 39% (OR 3.71) 3

• Once daily application of potent corticosteroids is equally effective as twice daily use (OR 0.97), so starting with once or twice daily is appropriate 3

Antihistamine Therapy for Pruritus and Scratch Prevention

• Prescribe oral cetirizine 10 mg daily (non-sedating) or hydroxyzine 10-25 mg QID or at bedtime (sedating option for nighttime itch) 1

• Antihistamines address the pruritus component and help break the itch-scratch cycle that has led to erosions 1

• Cetirizine is specifically recommended in dermatology guidelines for managing pruritus in eczematous conditions 4

Essential Emollient and Barrier Repair Therapy

• Apply hypoallergenic moisturizing creams or ointments at least once daily to the entire body, not just affected areas 1

• Emollients should be fragrance-free, oil-in-water creams or ointments rather than alcohol-containing lotions 1

• Application of moisturizers is critical as primary therapy for the underlying dry skin and helps prevent transepidermal water loss 1

• Avoid hot showers and excessive soap use, which further dehydrate the skin 1

Management of Erosions and Secondary Infection Risk

• The erosions from constant scratching represent grade 2 pruritus with skin changes (edema, excoriation, oozing/crusts) 1

• Monitor closely for secondary bacterial infection, as Staphylococcus aureus colonization occurs in 66-71% of moderate to severe eczema cases 5

• If signs of secondary infection develop (increased erythema, purulent drainage, crusting), consider adding topical or systemic antibiotics 1, 5

Treatment Duration and Follow-up

• Reassess after 2 weeks or sooner if symptoms worsen 1

• Once improvement occurs (resolution to grade 1 or less), transition to maintenance therapy with twice-weekly application of topical corticosteroids to commonly affected areas to prevent relapse 1, 3

• Weekend (proactive) therapy with topical corticosteroids reduces relapse risk from 58% to 25% (RR 0.43) 3

Critical Pitfalls to Avoid

• Do not use low-potency corticosteroids (like hydrocortisone 1%) for moderate-to-severe eczema on the body—they are inadequate for this severity 1, 3

• Avoid greasy creams for basic care as they may facilitate folliculitis development 1

• Do not underdose or undertreat due to steroid phobia—short-term use of potent topical corticosteroids on body surfaces is safe and necessary 1

• The risk of skin atrophy with short-term potent corticosteroid use is low (only 1% across trials), and most cases occurred with very potent preparations 3

• Reserve lower-potency corticosteroids (Class V/VI like hydrocortisone 2.5%, desonide) only for facial or intertriginous areas if those become involved 1