Guidelines for the management of adult eczema

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 [1] and the British Association of Dermatologists [2]. It is relevant to the treatment of eczema in New Zealand.

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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.

Primary treatment plan for eczema
Identify and eliminate/avoid exacerbating factors
  • Avoid, where possible, anything known to increase disease severity
  • Avoid extremes in temperature
  • Avoid clothes containing wool or other irritant fibres
  • Avoid use of soaps and detergents
  • Keep fingernails short
Keep skin hydrated
  • Eczema is characterized by reduced skin barrier function, which leads to enhanced water loss and dry skin therefore hydrate with warm soaking baths for at least 10 minutes followed by application of moisturizer/emollient.
  • Emollients are the cornerstone of eczema therapy and the quantity and frequency of use should be far greater than that of other therapies used.
Treat pruritus and prevent flares
  • Low-potency topical corticosteroids may be used for maintenance therapy if eczema is not controlled by emollients alone.
  • Antihistamines may provide relief for some patients, particularly those with concomitant urticarial or allergic rhinitis, or when taken at night when pruritus is usually worse.
  • Immunomodulatory agents (e.g. topical tacrolimus or pimecrolimus) may be used on the face, eyelids, and skin folds, for eczema unresponsive to low-potency topical corticosteroids.
Treat exacerbations (flares)
  • Intermediate- and high-potency topical corticosteroids can be used for short periods of time to treat exacerbations.
  • Ultrahigh-potency topical corticosteroids should only be used for very short periods (1-2 weeks) on non-facial and non-skinfold areas.
Treat secondary skin infections early
  • Skin infections with Staphylococcus aureus can be a recurrent problem. Treat with a short course of oral antibiotics.
  • Eczema can be complicated by recurrent viral skin infections, such as herpes simplex. Prompt diagnosis and treatment with systemic antiviral agents is recommended. Warts and molluscum contagiosum may also be more extensive than in children without eczema.
  • Fungal infections (yeast and dermatophytes) may complicate eczema and contribute to exacerbations. Diagnosis and appropriate antifungal treatment is recommended.

Follow-up therapy

Patient response to first-line therapy determines the next course of action. 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:

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.

Treatment of refractory eczema
Wet dressings
  • Application of wet dressings in combination with topical corticosteroids helps with skin barrier recovery, as it increases the efficacy of the corticosteroid and protects the skin from persistent scratching.
  • Overuse of wet dressings can cause skin maceration, folliculitis and secondary skin infections.
Phototherapy
  • Most commonly used phototherapy modality is narrow-band UVB.
  • Photochemotherapy with PUVA should be restricted to patients with severe widespread eczema.
  • Broadband UVB, and UVA1 where available, may also be useful.
Systemic immunomodulatory agents
  • Methotrexate, ciclosporin, mycophenolate mofetil, azathioprine, interferon-gamma and systemic corticosteroids have shown to provide benefit for patients with severe refractory eczema.
  • Use is limited by their potentially serious adverse effects.
Hospitalisation
  • Patient is removed from environmental allergens, irritants, and stressors.
  • Patient education and compliance with therapy is intensified.
Allergen immunotherapy
  • Possible consideration in selected eczema patients with associated aeroallergen sensitivity.

Pharmacological therapy in eczema

Emollients

Topical corticosteroids

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

Immunomodulatory agents

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

Antihistamines

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

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.

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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