What is the appropriate management for an acute atopic dermatitis (eczema) flare?

Treatment for Eczema Flare

For an acute atopic dermatitis flare in adults, use topical corticosteroids applied twice daily as first-line treatment, selecting potency based on body site (potent/very potent for trunk and limbs, mild-to-moderate for face and intertriginous areas), combined with liberal emollient use and consideration of sedating antihistamines for severe nighttime pruritus. 1, 2

First-Line Acute Flare Management

Topical Corticosteroids

• Apply topical corticosteroids no more than twice daily to inflamed areas, using the least potent preparation that controls the eczema 1
• Potency selection is critical: Use potent or very potent preparations for the trunk and extremities, but exercise caution with these categories and limit duration of use 1
• For facial and flexural areas, use mild-to-moderate potency corticosteroids to minimize risk of skin atrophy and pituitary-adrenal suppression 1
• High certainty evidence supports topical corticosteroids as the cornerstone of flare treatment 1, 2

Emollients and Skin Hydration

• Prescribe adequate amounts of emollients for liberal use throughout the day, independent of corticosteroid application 1
• Daily bathing with soap-free cleansers is conditionally recommended, though optimal frequency cannot be specified from available evidence 1, 2
• Emollients restore epidermal barrier function, which is central to disease pathophysiology 3

Topical Calcineurin Inhibitors as Alternative

• For facial or sensitive areas where corticosteroid adverse effects are concerning, use tacrolimus 0.03% or 0.1% ointment or pimecrolimus 1% cream 1, 2, 4
• These agents have high certainty evidence for efficacy and can be used in conjunction with topical corticosteroids 1, 2
• Tacrolimus and pimecrolimus avoid corticosteroid-related risks like skin atrophy, making them particularly valuable for long-term facial use 2, 4

Adjunctive Therapies During Flares

Antihistamines

• Sedating antihistamines (not non-sedating types) may be used short-term as adjuvant therapy for severe pruritus, particularly for nighttime use to improve sleep 1
• Their therapeutic value resides principally in sedative properties rather than antihistamine effects 1
• Large doses may be required in children; daytime use should be avoided 1
• Note the caveat: Tachyphylaxis can progressively reduce effectiveness 1

Wet Dressings

• For moderate-to-severe flares, wet dressings are conditionally recommended to enhance treatment efficacy 1, 5
• This technique can be particularly useful for healing lichenified eczema 1

Infection Management

• If secondary bacterial infection is suspected (increased weeping, crusting, pustules), add flucloxacillin as the first-choice antibiotic for Staphylococcus aureus coverage 1
• Use phenoxymethylpenicillin if beta-hemolytic streptococci are isolated 1
• Erythromycin is appropriate for flucloxacillin resistance or penicillin allergy 1
• For eczema herpeticum (viral superinfection), initiate oral acyclovir early; use intravenous acyclovir in ill, febrile patients 1
• Bleach baths may be suggested for patients with moderate-to-severe AD and clinical signs of secondary bacterial infection 1, 5

Newer Topical Agents

JAK Inhibitors and PDE-4 Inhibitors

• For mild-to-moderate AD, ruxolitinib cream (JAK1/JAK2 inhibitor) is recommended with moderate certainty evidence showing significant improvement in disease severity and pruritus 1, 6
• Crisaborole ointment (PDE-4 inhibitor) is recommended for mild-to-moderate AD with high certainty evidence 1, 2, 4
• These agents represent effective alternatives when traditional therapies are insufficient 7, 8

What NOT to Do

• Do not routinely use topical antimicrobials (conditionally recommended against due to low evidence) 1
• Do not use topical antihistamines (conditionally recommended against) 1
• Do not use non-sedating oral antihistamines as they have little to no value in atopic eczema 1, 2
• Avoid systemic corticosteroids for acute flares unless all other avenues have been exhausted; they should never be considered lightly and are particularly important to avoid during crises 1

Maintenance After Flare Control

• Once the flare is controlled, transition to proactive maintenance therapy with topical corticosteroids 1-2 times per week or topical calcineurin inhibitors 2-3 times per week applied to previously involved skin to prevent subsequent flares 1, 4
• This approach has high certainty evidence for reducing disease relapse 1

When to Escalate

• Refer to a specialist if the patient fails to respond to first-line management after reinforcing compliance with basic therapy 1
• Consider systemic therapies (cyclosporine, dupilumab, JAK inhibitors like baricitinib, upadacitinib, or abrocitinib) or phototherapy for refractory moderate-to-severe disease 4, 7, 8