first-line therapy

Last edited 06/2023 and last reviewed 08/2023

Treatment options include:

• emollients - combat dry skin
• soap substitutes
  • soap is drying as it removes natural oils from the skin. A soap substitute (e.g. aqueous cream) should be used to wash with instead
• bath/shower emollients
• topical emollients These should be applied to all areas at least twice a day
  
  
• topical corticosteroids - used to control inflammation (see linked item)
  • work by suppressing the inflammatory response in eczematous skin (1,2,3)
  • should be used in addition to emollients where there is active inflammation
  • the least potent steroid required to suppress the inflammation should be used, although in practice it is common to use a more potent steroid to start with and then 'drop down' to a milder preparation once the acute inflammation is improving
  • patients should be advised to continue with emollient therapy during treatment with topical corticosteroids
  • patients with atopic eczema should be advised to apply topical corticosteroids once daily (4)
    • if there is an inadequate response to once daily application, the frequency should be increased to twice daily
  • twice weekly maintenance therapy with a topical corticosteroid should be considered in patients with moderate to severe atopic eczema experiencing frequent relapses (4)
  • topical corticosteroids should be used with caution in the periocular region
  • use topical corticosteroids of appropriate potency to treat affected sites
    
    
• antibiotics - control of staphylococcal overgrowth e.g. a seven-day course of flucloxacillin or erythromycin is first line if signs of moderate to severe infection (1). The same MeReC bulletin states that there is no evidence that topical antibiotic/corticosteroid preparations are superior to corticosteroids alone and topical antibiotics should be avoided or reserved for single small lesions only. Also there is no evidence that bath oils containing antimicrobials are any more effective than standard bath oils and their routine use cannot be recommended (1)
  
  
• antivirals - eczema herpeticum should be suspected in atopic patients with a sudden, severely painful exacerbation with vesicular or ulcerated lesions
  • in severe cases then prompt admission may be required
    • an emergency referral to a dermatologist or paediatrician should be arranged by telephone where there is clinical suspicion of eczema herpeticum (3,4)
  • treatment is with oral aciclovir
  • topical corticosteroids should not be used in the presence of herpes infection (2)
    
    
• antihistamines - sedative antihistamines combat itching
  
  
• topical calcineurin inhibitors
• topical calcineurin inhibitors (including tacrolimus and pimecrolimus) are licensed for use in adults and children two years of age and older as second-line treatments for moderate to severe eczema that has not been controlled by topical corticosteroids, when there is serious risk of important adverse eIects from further topical corticosteroid use (particularly irreversible skin atrophy)
(5)

• Other treatment options that may be used in management of eczema include:
• cotten bandages and dressings:
  • wet wrapping is a technique popular with paediatric patients, particularly at night-time
    • large amounts of emollient and sometimes a mild topical steroid are applied under a damp layer of bandage (e.g. Tubifast); a second dry layer is then applied on top. As the bandage dries the skin cools, therefore reducing pruritus
    • the occlusion results in increased absorption of the topical steroid and therefore care is required
    • the technique needs to be demonstrated to the patient's parents
    • is contraindicated in the presence of secondary infection.
• coal tar and ichthammol :
  • coal tar and the less irritating shale derivative ichthammol are both used in a variety of preparations to treat eczema
  • most suitable for chronic lichenified eczema and may be applied as crude coal tar, tar-containing creams, eg Clinitar, or in combination with zinc paste either as a cream or a bandage, eg Ichthopaste
  • side-effects comprise of skin irritation, folliculitis and staining of skin and clothes
  • not suitable for facial use
• salicylic acid - a keratolytic- may be used in combination preparations. Makes the upper layers of the skin more easy to peel off
• potassium permanganate - 1:8000 - mild antiseptic and a drying agent

Notes (3):

• oral antihistamines should not be used routinely in the management of atopic eczema in children
  • healthcare professionals should offer a 1-month trial of a non-sedating antihistamine to children with severe atopic eczema or children with mild or moderate atopic eczema where there is severe itching or urticaria. Treatment can be continued, if successful, while symptoms persist, and should be reviewed every 3 months
  • healthcare professionals should offer a 7-14 day trial of an age-appropriate sedating antihistamine to children aged 6 months or over during an acute flare of atopic eczema if sleep disturbance has a significant impact on the child or parents or carers. This treatment can be repeated during subsequent flares if successful
• use of topical antibiotics in children with atopic eczema, including those combined with topical corticosteroids, should be reserved for cases of clinical infection in localised areas and used for no longer than 2 weeks
• eczmea herpeticum in a child
  • if eczema herpeticum (widespread herpes simplex virus) is suspected in a child with atopic eczema, treatment with systemic aciclovir should be started immediately and the child should be referred for same-day specialist dermatological advice. If secondary bacterial infection is also suspected, treatment with appropriate systemic antibiotics should also be started
  • if eczema herpeticum involves the skin around the eyes, the child should be treated with systemic aciclovir and should be referred for same-day ophthalmological and dermatological advice

Reference:

• (1) MeReC Bulletin 2003; 14(1): 1-4.
• (2) Prescriber 2001; 12 (12).
• (3) NICE (June 2023).Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years.
• (4) SIGN (March 2011). Management of atopic eczema in primary care
• (5) Sawangjit R et al. Systemic treatments for eczema: a network meta-analysis. Cochrane Database of Systematic Reviews 2020, Issue 9. Art. No.: CD013206. DOI:10.1002/14651858.CD013206.pub2.