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Author: Vanessa Ngan, Staff Writer, 2014. Reviewed and updated by Dr Steven Lamb, Dermatologist, 4 February 2014.
This document incorporates and summarises guidelines recently published by the American Academy of Dermatology  and the British Association of Dermatologists . It is relevant to the treatment of eczema in New Zealand.
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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.
|A primary treatment plan for eczema|
|Identify and eliminate/avoid exacerbating factors||
|Keep skin hydrated||
|Treat pruritus and prevent flares||
|Treat exacerbations (flares)||
|Treat secondary skin infections early||
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:
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.
|Treatment of refractory eczema|
|Systemic immunomodulatory agents||
Topical corticosteroids are recommended when emollients alone do not control eczema.
Topical immunomodulatory agents, which include tacrolimus and pimecrolimus, are suitable alternatives to topical corticosteroids.
Little evidence exists to demonstrate that antihistamines are effective in relieving pruritus in patients with eczema.
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.
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.
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.
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