Eczema Management

Introduction to Eczema Treatment

The American Academy of Dermatology and the British Journal of Dermatology recommend topical corticosteroids as the mainstay of treatment for localized contact dermatitis and eczema, with the goal of reducing inflammation and preventing infection 1, 2, 3
The treatment approach should be individualized, considering factors such as disease severity, patient age, and affected body area 1, 2, 3

Moderate potency topical corticosteroid cream, such as clobetasone butyrate 0.05%, is recommended for the treatment of chronic eczema, providing sufficient anti-inflammatory effect while balancing the risk of side effects 3
Topical corticosteroids are classified into different potency classes, with mometasone furoate 0.1% being a potent (class 3) topical corticosteroid, and the ointment formulation providing slightly higher potency than the cream due to its occlusive properties 3
For facial dermatitis, consider medium potency (class 4-5) corticosteroids for short-term use only in cases of moderate inflammation, and apply low potency (class 6-7) corticosteroids such as hydrocortisone 1% once or twice daily until significant improvement 2, 4
High-potency steroids should be avoided on the face due to increased risk of skin atrophy, perioral dermatitis, and rosacea, as warned by the American Academy of Dermatology and the Journal of Microbiology, Immunology and Infection 2, 4

If infection is suspected, topical antibiotics in an alcohol-free formulation should be added for at least 14 days 3
Antibiotics are important for treating secondary bacterial infection, with flucloxacillin usually most appropriate for treating Staphylococcus aureus, according to the British Medical Journal guidelines, and phenoxymethylpenicillin can be used for B-hemolytic streptococci infections 5
Erythromycin can be used when there is resistance to flucloxacillin or penicillin allergy, as recommended by the British Medical Journal, and topical antibacterial moisturizers, containing triclosan or chlorhexidine, can be used if a bacterial infection is suspected, as recommended by the American Academy of Dermatology 5, 6
Topical antifungal creams, such as clotrimazole or miconazole, can be used if a fungal infection is suspected, as suggested by the American Academy of Pediatrics 7

If no improvement is seen after 2 weeks, increasing the potency to a potent steroid, such as betamethasone valerate 0.1%, may be considered 3
Oral steroids are indicated for contact dermatitis involving greater than 20% of body surface area or when topical treatments have failed, with the BMJ noting that oral steroids can provide rapid relief within 12-24 hours, but also carry a risk of rebound dermatitis if discontinued too quickly, and can cause systemic side effects including suppression of the pituitary-adrenal axis and potential growth interference in children 5
Consider proactive, intermittent application (twice weekly) for maintenance therapy in recurrent cases of facial dermatitis, as recommended by the Journal of Microbiology, Immunology and Infection 4
Topical calcineurin inhibitors (TCIs), such as pimecrolimus 1% cream or tacrolimus 0.03% ointment, can be considered as steroid-sparing alternatives for maintenance therapy, as suggested by the American Academy of Dermatology and the Journal of Microbiology, Immunology and Infection 8, 4

Emollients or moisturizers should be applied frequently throughout the day, especially after bathing, and at least 15-30 minutes before or after steroid application, choosing fragrance-free, preservative-free formulations in tubes rather than jars, as recommended by the American Academy of Dermatology 9, 3
Sedating antihistamines can be used short-term during relapses with severe itching, but non-sedating antihistamines have little to no value in atopic eczema, as stated by the British Medical Journal, and the BMJ recommends using sedating antihistamines for severe pruritus during flares 5, 5
Chlorhexidine-containing products are not recommended for infants younger than two months due to potential side effects, as stated in Clinical Nutrition, and topical antihistamines may increase the risk of contact dermatitis and are not recommended, according to the Journal of Microbiology, Immunology and Infection 10, 4

The British Journal of Dermatology recommends patch testing to identify specific allergens if no improvement is seen after 2 weeks of appropriate treatment, and the American Academy of Dermatology recommends consulting a dermatologist if no significant improvement is seen after 7 more days of adjusted treatment 1, 9
Referral to dermatology for patch testing should be considered if no improvement is seen after 2 weeks of appropriate treatment, as recommended by the British Journal of Dermatology, and a dermatologist can properly diagnose whether this is a fungal infection, allergic contact dermatitis, irritant contact dermatitis, or another skin condition entirely 1, 9