Treatment of Severe Eczema

First-Line Treatment

The American Academy of Dermatology recommends initiating treatment with potent topical corticosteroids applied once daily, combined with liberal emollient use, for severe eczema 1
Potent topical corticosteroids should be used with caution on thin-skinned areas, such as the face, neck, flexures, and genitals, due to the risk of atrophy 1
The use of the least potent preparation that controls symptoms is recommended, and undertreatment with inappropriately weak steroids should be avoided 1

Liberal and frequent application of emollients is essential for maintenance therapy, even when eczema appears controlled 1
Emollients should be applied immediately after bathing to provide a surface lipid film that retards water loss 1
Soap-free cleansers and avoidance of alcohol-containing products are recommended 1

The presence of increased crusting, weeping, or pustules may indicate Staphylococcus aureus superinfection, and flucloxacillin or erythromycin may be prescribed as first-line oral antibiotics 1, 2
Topical corticosteroids should be continued during infection when appropriate systemic antibiotics are given concurrently 1
Eczema herpeticum is a medical emergency, and oral acyclovir should be initiated immediately 1

Referral to dermatology for second-line options is recommended if severe eczema fails to respond to optimized first-line therapy after 4 weeks 1
Topical calcineurin inhibitors, such as tacrolimus 0.1%, may be effective for severe eczema, but have a major disadvantage of application-site burning/stinging 2
Phototherapy, including narrowband UVB and PUVA, may be effective for widespread severe eczema, but has a concern of long-term risk of premature skin aging and cutaneous malignancies 1, 2

Systemic corticosteroids have a limited but definite role in "tiding over" occasional patients during acute severe flares, but should never be used for maintenance treatment 4, 5, 1
The decision to use systemic steroids should never be taken lightly due to risks of pituitary-adrenal suppression and steroid-related mortality 1

Twice-weekly application of topical corticosteroids to previously affected areas may prevent flares and reduce relapse risk from 58% to 25% 1
Liberal emollient use should be continued daily 1

Referral to dermatology is recommended for failure to respond to potent topical corticosteroids after 4 weeks, suspected eczema herpeticum, need for systemic therapy or phototherapy, or diagnostic uncertainty 1, 5

Undertreatment due to steroid phobia should be avoided, and patients should be explained that short-term use of appropriate potency steroids is safe and necessary 1
Withholding steroids during infection should be avoided, and topical corticosteroids should be continued when appropriate antibiotics are given for bacterial superinfection 1
Continuous use without breaks should be avoided, and "steroid holidays" should be implemented when possible to minimize adverse effects 1