Management of Eczema with Oral Treatments

Oral Antihistamines for Symptom Management

Sedating antihistamines are the only oral antihistamines with proven value in eczema, working primarily through their sedative properties rather than histamine blockade 1, 3
Use sedating antihistamines exclusively at nighttime to help patients sleep through severe pruritus episodes while avoiding daytime sedation 5, 4
Large doses of sedating antihistamines may be required in children to achieve adequate symptom control 5, 6
Sedating antihistamines should be used as short-term adjuvant therapy during relapses associated with severe pruritus, not as continuous treatment 1, 3
Non-sedating antihistamines have little or no value in atopic eczema and should not be used routinely 1, 3, 4, 6
Tachyphylaxis develops with prolonged use of antihistamines, progressively reducing their effectiveness 1, 6

Oral antibiotics are important for treating overt secondary bacterial infection, indicated by crusting, weeping, or failure to respond to topical treatment 1, 7, 5
Flucloxacillin is the first-line choice for Staphylococcus aureus, the most common pathogen 7, 5, 2, 6
Erythromycin can be used for penicillin allergy or flucloxacillin resistance 7, 5, 2
Phenoxymethylpenicillin can be used if beta-hemolytic streptococci are isolated 7, 5
Oral acyclovir should be given early for eczema herpeticum, indicated by grouped, punched-out erosions or vesiculation 7, 5, 2, 6

Systemic corticosteroids have a limited but definite role only for occasional patients with severe atopic eczema 7, 5, 2, 4
Systemic corticosteroids should never be considered for maintenance treatment until all other avenues have been explored 7, 5, 2, 4
The decision to use systemic steroids should never be taken lightly 7, 5, 2
Try to avoid oral corticosteroids during acute crises 7, 5, 2
Risk of pituitary-adrenal axis suppression is a concern with systemic corticosteroids 5, 2
Possible interference with growth in children is a concern with systemic corticosteroids 5, 2

Avoid soaps and detergents as they remove natural skin lipids—use dispersible cream as soap substitute 1, 3
Keep nails short to minimize scratching damage 1, 3, 4
Avoid irritant clothing (wool); wear cotton next to skin 1, 3
Avoid temperature extremes 1, 3
Evidence for dietary restriction is insufficient to make routine recommendations 5, 2
Consider dietary trial only when patient history strongly suggests specific food allergy or when widespread active eczema fails first-line treatment 7, 5

Most patients should be managed without oral medications, using topical corticosteroids, emollients, and avoidance of irritants as first-line treatment 1, 3, 4
For severe nighttime pruritus during flares, add sedating antihistamines at bedtime only 1, 4, 6
For bacterial superinfection, add oral flucloxacillin 7, 5, 2
For eczema herpeticum, add oral acyclovir immediately 7, 5, 2
For severe refractory cases only, consider a short course of systemic corticosteroids after exhausting all other options 7, 5, 2, 4