Topical Treatment for Nummular Eczema

Initial Management

The American Academy of Dermatology recommends starting with high-potency topical corticosteroid (mometasone furoate 0.1% ointment) applied twice daily to the affected coin-shaped plaques, with a strength of evidence rated as high 1.
Applying liberal amounts of emollients throughout the day, especially after bathing, is crucial to maintain skin hydration, as suggested by the National Eczema Association, with moderate evidence 1, 2.
Using dispersible cream as a soap substitute and avoiding harsh soaps/detergents that strip natural skin lipids is recommended by the American Academy of Dermatology, with low evidence 1.
Avoiding extreme temperatures and irritant clothing (wool); preferring cotton clothing is advised by the National Eczema Association, with low evidence 1.

If significant improvement occurs, stepping down to moderate-potency corticosteroid and continuing twice-daily application is recommended by the American Academy of Dermatology, with moderate evidence 2.
If minimal or no improvement, considering secondary bacterial infection (particularly Staphylococcus aureus) and adding flucloxacillin (or erythromycin if penicillin-allergic) is suggested by the Infectious Diseases Society of America, with high evidence 1, 2.

Transitioning to twice-weekly application of the corticosteroid to previously affected areas to prevent relapse is recommended by the National Eczema Association, with moderate evidence 2.
Continuing daily emollient use indefinitely is advised by the American Academy of Dermatology, with high evidence 1, 2.
Using the least potent preparation required to maintain control, with periodic treatment breaks when possible to minimize side effects, is suggested by the American Academy of Dermatology, with low evidence 1.

Avoiding prolonged high-potency steroid use (limit to 2-4 weeks maximum at full strength) to prevent skin atrophy and systemic effects, particularly important if the patient is on systemic corticosteroids for lupus, is recommended by the American College of Rheumatology, with high evidence 2.
Mometasone is preferred over triamcinolone due to its lower systemic absorption, reducing the risk of hypothalamic-pituitary-adrenal axis suppression, as suggested by the Endocrine Society, with moderate evidence 2.

Not using very potent corticosteroids (like clobetasol) as first-line for nummular eczema—reserving these for severe, refractory cases, is recommended by the American Academy of Dermatology, with high evidence 1.
Not prescribing non-sedating antihistamines—they have little to no value in nummular eczema; sedating antihistamines at night may help during severe pruritic episodes only, as suggested by the American Academy of Dermatology, with low evidence 1.
Not overlooking secondary infection—if lesions are weeping, crusted, or not responding to appropriate topical steroids within 2 weeks, adding antibiotics is recommended by the Infectious Diseases Society of America, with high evidence 1, 2.
Avoiding alcohol-containing lotions in favor of ointments or oil-in-water creams, which are less irritating, is advised by the National Eczema Association, with low evidence 2.