Guidelines for the management of adult eczema

This document incorporates and summarises guidelines recently published by the American Academy of Dermatology [1] and the British Association of Dermatologists [2]. It is relevant to the treatment of eczema in New Zealand.

Read these guidelines in association with:

• Guidelines for the diagnosis and assessment of eczema
• Guidelines for the outpatient management of childhood eczema

First-line therapy

Treatment goals should be to reduce the number and severity of flares and increase disease-free periods. Approach to treatment is shown in the following table.

Follow-up therapy

Patient response to first-line therapy determines the next course of action. The response can be classed as complete response, partial response, or treatment failure. Complete response is rare unless there is a clear-cut exacerbating factor that can be removed or corrected. Most patients will have a partial response since eczema is a chronic relapsing skin disease. Patients who do not respond to first-line therapy need to be completely re-assessed and if necessary referred to a dermatologist for specialist treatment, or for consideration of other conditions.

Patients whom partially respond will experience reduced pruritus and severity of the condition. These patients will need a long-term follow-up plan which includes:

• Education of the patient and family members about the chronic nature of eczema, exacerbating factors, and appropriate therapy to achieve effective control of their condition. This is important as it ensures cooperation and compliance which leads to better outcomes.
• Patient and caregivers educated about how to monitor their condition and when to seek medical help.
• Review of therapy at follow-up appointments to provide the most appropriate treatment according to the severity of the disease.
• Introduction to patient support organisations that provide up-to-date information about eczema.

Treatment of severe eczema

Patients with severe eczema or those that do not respond to first-line therapy should be referred to a dermatologist for evaluation and treatment. Second-line therapies used in refractory eczema are shown in the table below.

Pharmacological therapy in eczema

Emollients

• Almost all patients with eczema suffer from dry skin and require the use of emollients to ensure maximal re-hydration of the skin.
• Emollients are available in the form of lotions, creams, and ointments. Lotions and creams can sometimes be irritating because of added preservatives, solubilisers, and fragrances. Occlusive ointments are very effective on very dry, thicker and scaly areas of skin but some patients may find them too greasy.
• Emollients are best applied when skin is moist (after bathing) but can and should be applied at other times as well. Ideally, they should be applied every 4 hours or at least 3 to 4 times per day.
• Bath oil and emollient soap substitutes should be used instead of soap and cleansers.
• Emollients help to control pruritus and consistent use reduces the amount and needs for topical corticosteroids.
• Many patients underestimate the amount needed and frequency of application to achieve the greatest benefit. Emollients should be prescribed in large quantities, adult patients may use up to 500 g/week or more, and children around 250 g/week.
• Pump dispensers and the use of spatulas to remove emollients from pots reduce bacterial contamination.

Topical corticosteroids

Topical corticosteroids are recommended when emollients alone do not control eczema.

• The potency of the corticosteroid should be matched to the disease severity and the affected site. Only use lower potency corticosteroids on the face and flexures.
• The weakest corticosteroid that controls the condition should be used. A step-up approach, less potent to more potent, or a step-down approach, more potent to less potent should be employed.
• Use the fingertip unit ( FTP) as a guide to the amount of topical steroid to use different areas of the body.
• Ideally, corticosteroid use should be limited to a few days to a week for acute eczema, and up to 4 to 6 weeks to gain remission for chronic eczema.
• Higher-potency corticosteroids should only be used in patients with very severe eczema and for only very short periods of time (1 to 3 weeks).
• Potent corticosteroids should not be used without specialist advice in infants and young children. The potential for prolonged use to cause adrenal suppression is greatest in these patients. Growth charts should be recorded.
• Keep patients using moderate and potent corticosteroids under review. Look out for local and systemic side effects.
• Emollients can be applied before or after application of topical corticosteroid; the optimal order and timing of the combination are unknown.[5]

Immunomodulatory agents

Topical immunomodulatory agents, which include tacrolimus and pimecrolimus, are suitable alternatives to topical corticosteroids.

• Unlike topical corticosteroids, these agents do not cause skin atrophy, so can be used on the face, eyelids, and skin folds when low-potency topical corticosteroids are ineffective.
• Use may be limited in some patients, as they can cause a transient sensation of warmth or burning and localised itching, especially during the first week of application.
• Tacrolimus ointment applied twice daily two times per week to eczema-prone areas is useful in preventing future flares.
• One concern with these agents is an increased risk of viral infections such as herpes simplex and molluscum contagiosum. Patients must be monitored for this possible complication.
• Currently, these agents should not be used a first-line therapy unless there are clear reasons to avoid or reduce the use of topical corticosteroids.

Antihistamines

Little evidence exists to demonstrate that antihistamines are effective in relieving pruritus in patients with eczema.

• Oral non-sedating antihistamines may provide relief for some patients, particularly those with concomitant urticaria or allergic rhinitis.
• Sedating antihistamines taken at bedtime may allow sounder sleep, as pruritus is often worse at night.

Antimicrobials

Skin infections with Staphylococcus aureus are a recurrent problem in patients with eczema, and patients with moderate-to-severe eczema have been found to make IgE antibodies against staphylococcal toxins present in their skin.

• A 7-day course of oral flucloxacillin is most appropriate for treating Staphylococcus aureus. Other penicillinase-resistant penicillins include dicloxacillin, oxacillin and cloxacillin.
• In areas with high levels of methicillin-resistant Staphylococcus aureus, take skin swabs and start treatment with clindamycin, doxycycline, or trimethoprim-sulfamethoxazole while waiting for culture results.
• Soaking for 10 minutes twice weekly in dilute bleach bath (sodium hypochlorite) may reduce the severity of eczema and skin infections.

Viral infections such as herpes simplex can complicate eczema, especially if it develops into eczema herpeticum. Consider herpes simplex when infected skin lesions do not respond to oral antibiotics. Viral swabs for culture or polymerase chain reaction testing (PCR) can be confirmatory.

• Herpes simplex infections should be promptly treated with oral aciclovir 400 mg 5 times daily in patients with widespread eczema, as life-threatening dissemination has been reported. Hospitalisation and intravenous aciclovir may be indicated.

Malassezia colonisation can aggravate eczema around the head and neck. Malassezia species are lipophilic yeasts that are commonly found in seborrhoeic areas. Malassezia is difficult to culture but mycelia and arthrospores can be seen on microscopy of a KOH preparation. Depending on the severity, a trial of topical or systemic antifungal treatment (an azole) may be warranted.

Link to:

• Guidelines for the diagnosis and assessment of eczema
• Guidelines for the outpatient management of childhood eczema.