Treatments for Eczema

Eczema should be managed following a stepped approach in which treatment steps are tailored according to the severity of the eczema. Using this approach, medications and alternate treatment choices will be added or removed and frequency of application increased or decreased in accordance with changes in disease severity.

• Moisturizers should always be used, whether or not symptoms are present.
• When more than one medication is applied to the skin, they should be applied one at a time, with several minutes between applications.
• To achieve maximum benefit, products that contain medications should be applied to the skin before applying moisturizers.

Topical Corticosteroids are the drug of choice for acute eczema flare ups. They have a rapid anti-inflammatory effect which helps clear redness and a rapid anti-itching effect that works within minutes.

There are a large number of topical corticosteroids available, each varying in potency. When treating infants and children, the face or areas close to the face, low potency steroids should be tried first. If low-potency steroids do not work then a mid-potency product should be tried. High potency steroids are sometimes required for thicker skin such as the palms of the hands, soles of the feet or thickened plaques.

For acute flare ups, a thin film of the steroid should be applied to moistened skin when possible at least once to four times daily for one to two weeks, until all or most of the rash is gone. Then the lowest possible strength of corticosteroid should be used at a frequency that keeps the eczema under control. For maintenance therapy a low potency steroid may be used once daily or a mid potency steroid may be used once to twice weekly.

Side effects of corticosteroids are related to the strength of the product, frequency of application, duration of use, and site of application.

• thinning of the skin
• an increase in stretch marks
• an increase in skin infections
• a rash around the mouth when steroids are used on the face
• growth suppression (rarely)
• suppression of the hypothalamic-pituitary adrenal axis (rarely)

Topical Immune Modulators (topical calcineurin inhibitors)

This new class of drugs has brought a great deal of relief to many eczema sufferers. These medications work on the immune system to reduce the inflammatory response.

They decrease itching and rash in both adults and children. They are applied twice daily during a flare up and for one to three weeks after complete clearance of symptoms. Improvement of symptoms using these products is sometimes seen within the first week of treatment. Effectiveness has been maintained for up to twelve months in children and three years in adults with no skin thinning, no increase in infection and no increase in stretch marks.

The most common side effect of topical immune modulators was mild to moderate itching at the application site, which gradually went away within the first week of continued use. Absorption of these medications is minimal. However since they are immunosuppressants infections should be watched for, despite the risk being low.

Long term risk studies are still not available as these products are relatively new.

Phototherapy

Eczema often improves with exposure to natural sunlight. Various ultraviolet light treatments such as UVA, UVB, and UVA/UVB combinations have been successfully tried. Because of damaging effects of ultraviolet light, such as premature aging and increase in cancer risk prolonged periods of sunlight exposure are not recommended. Patients should follow the recommendations of their dermatologist with regard to duration of sunlight exposure.

Systemic Immunomodulating Agents

Oral and injectable immunosuppressants are available for use in patients with atopic dermatitis which has failed to respond to other treatments. Oral corticosteroids or cyclosporine have been used successfully in cases of severe, intractable eczema. These medications though sometimes very effective have a number of side effects, drug interactions and long term maintenance therapy issues which need to be carefully considered and monitored.

Antihistamines-The benefit of antihistamines comes from the side effect of drowsiness which helps the patient sleep despite the itching. Antihistamines should be reserved for bedtime, since daytime use may interfere with the patient's ability to concentrate on school or work. Antihistamines that do not cause drowsiness are not believed to help with the itching caused by eczema. Antihistamines should not be used in children two years of age and under without seeking the advice of a physician.