What is the recommended treatment approach for generalized eczema?

Treatment of Generalized Eczema

For generalized eczema, apply topical corticosteroids no more than twice daily using the least potent preparation that controls symptoms, combined with liberal emollient use as the cornerstone of therapy. 1

Immediate Treatment Strategy

Topical Corticosteroid Application

• Select corticosteroid potency based on body site: use low-potency preparations (hydrocortisone 1–2.5%) for face, neck, flexures, and genitals where skin is thin; moderate-to-potent preparations (mometasone, clobetasol) for trunk and extremities. 1
• Apply no more than twice daily to all affected areas, using the minimum potency that achieves control. 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, rather than stopping treatment completely. 1
• Implement short "steroid holidays" when feasible to reduce adverse effects such as skin atrophy, even on body sites. 1
• Choose ointments for very dry skin, creams for daily non-greasy use, and lotions for hair-bearing areas. 1

Essential Emollient Therapy

• Apply emollients liberally at least once daily to the entire body, even to uninvolved skin. 1
• Apply immediately after bathing (within 10–15 minutes) to damp skin to create a surface lipid film that prevents transepidermal water loss. 1
• Continue aggressive emollient use during clear periods—this provides steroid-sparing benefits and extends remission. 1
• Substitute regular soaps with soap-free cleansers or dispersible creams because soaps strip natural lipids. 1

Managing Secondary Infection

Bacterial Superinfection

• Monitor for increased crusting, weeping, purulent exudate, or pustules—these indicate Staphylococcus aureus infection. 1
• Prescribe oral flucloxacillin as first-line antibiotic; use erythromycin for penicillin allergy or flucloxacillin resistance. 1
• Do not discontinue topical corticosteroids when infection is present—continue them concurrently with appropriate systemic antibiotics. 1
• Obtain bacterial cultures if the patient fails to improve after initial antibiotic treatment. 1

Eczema Herpeticum (Medical Emergency)

• Suspect eczema herpeticum if you observe grouped vesicles, punched-out erosions, or sudden deterioration with fever. 1
• Initiate oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients. 1

Pruritus Management

• Sedating antihistamines (hydroxyzine, diphenhydramine) may improve nighttime itching through their sedative effect, not direct antipruritic action. 1
• Non-sedating antihistamines have no proven benefit in atopic eczema and should not be prescribed. 1
• Use sedating antihistamines only short-term and intermittently to aid sleep—they must not replace topical anti-inflammatory therapy. 1

Systemic Therapy for Severe Disease

• Reserve systemic immunosuppressants (cyclosporine 3–6 mg/kg/day, methotrexate 7.5–25 mg/week, azathioprine 1–3 mg/kg/day) for patients with severe, recalcitrant eczema who have failed adequate topical therapy. 1
• Narrowband UVB phototherapy (312 nm) is an alternative for patients who cannot receive systemic agents, but only after failure of adequately potent topical corticosteroids and consistent emollient use. 1
• Oral systemic steroids should be used only for acute severe flares requiring rapid control when topical therapy has failed, for short-term "tiding over" during crisis periods—never for maintenance treatment. 1
• Pituitary-adrenal suppression and corticosteroid-related mortality are significant risks with prolonged oral steroid use. 1

Alternative Topical Anti-Inflammatory Agents

• Topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus 1% cream) can be applied 2–3 times per week as proactive maintenance after disease stabilization in patients where corticosteroid-related concerns exist. 1
• Tacrolimus 0.1% and ruxolitinib 1.5% rank among the most effective treatments for improving patient-reported symptoms and clinician-reported signs. 2
• Local application site reactions (burning, stinging) are most common with tacrolimus 0.1% and crisaborole 2%, and least common with topical steroids. 2
• Pimecrolimus should not be used in patients with generalized erythroderma, as safety has not been established in this population. 3

Environmental and Lifestyle Modifications

• Keep fingernails short to minimize skin trauma from scratching. 1
• Wear smooth cotton garments and avoid irritant fabrics such as wool. 1
• Maintain a cool ambient temperature and prevent excessive sweating. 1
• Avoid hot showers and excessive soap use. 4

Referral and Escalation Criteria

• Refer patients who do not respond to moderate-to-potent topical corticosteroids after 4 weeks of appropriate use. 1
• Seek specialist management when systemic therapy (phototherapy, oral immunosuppressants, biologics) is contemplated. 1
• Promptly refer for emergency evaluation if eczema herpeticum is suspected. 1

Common Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present—they remain the primary treatment when appropriate systemic antibiotics are given. 1
• Do not use topical corticosteroids continuously without breaks—implement "steroid holidays" when possible. 1
• Patients' or parents' fears of steroids often lead to undertreatment—explain the different potencies and the benefits/risks clearly. 1
• Avoid very potent corticosteroids in thin-skinned areas (face, neck, flexures, genitals) where risk of atrophy is higher. 1
• Short-term use of any topical steroid potency does not increase skin thinning risk, but longer-term use (6–60 months) carries a 0.3% risk. 2