What is first line treatment for eczema?

1.

Leung, Donald Y.M., Sicherer, Scott H. (2025). Atopic Dermatitis (Atopic Eczema). In Nelson Textbook of Pediatrics (pp. 1410). DOI: 10.1016/B978-0-323-88305-4.00186-3

Because patients with AD have impaired skin barrier function from reduced filaggrin and skin lipid levels, they present with diffuse, abnormally dry skin, orxerosis.Moisturizers are first-line therapy.Lukewarm soaking baths or showers for 15-20 minutes followed by theapplication of an occlusive emollient to retain moisture provide symptomatic relief. Hydrophilic ointments of varying degrees of viscosity can be used according to the patient’s preference. Occlusive ointments are sometimes not well tolerated because of interference with the function of the eccrine sweat ducts and may induce the development of folliculitis. In these patients, less occlusive agents should be used. Several prescription (classified as a medical device) “therapeutic moisturizers” or “barrier creams” are available, containing components such as ceramides and filaggrin acid metabolites intended to improve skin barrier function. There are minimal data demonstrating their efficacy over standard emollients. Hydration by baths or wet dressings promotes transepidermal penetration of topical glucocorticoids. Dressings may also serve as effective barriers against persistent scratching, in turn promoting healing of excoriated lesions. Wet dressings are recommended for use on severely affected or chronically involved areas of dermatitis refractory to skin care. It is critical that wet dressing therapy be followed by topical emollient application to avoid potential drying and fissuring from the therapy. Wet dressing therapy can be complicated by maceration and secondary infection and should be closely monitored by a physician.

2.

Lim, Henry W., Gelfand, Joel M. (2024). Eczemas, Photodermatoses, Papulosquamous (Including Fungal) Diseases, and Figurate Erythemas. In Goldman-Cecil Medicine (pp. 2701). DOI: 10.1016/B978-0-323-93038-3.00405-6

The therapeutic ladder consists of (1) emollients; (2) topical corticosteroid ointments (e.g., triamcinolone ointment, 0.1% twice daily for 2 to 4 weeks), or topical calcineurin inhibitors (tacrolimus ointment, 0.1%, or pimecrolimus cream, 1% twice daily); (3) oral antihistamines (same dose range as nummular dermatitis); and (4) NB-UVB phototherapy.Options for poorly responsive disease include crisaborole (a phosphodiesterase 4 inhibitor) 2% ointment applied twice daily,ruxolitinib (Janus kinase inhibitor) cream 1.5% twice daily, dupilumab (an interleukin-4 [IL-4] receptor α-antagonist) at 300 mg subcutaneously every other week,A2-A3btralokinumab (an IL-13 receptor blocker at 300 mg subcutaneously every other week to every 4 weeks), and two oral Janus kinase inhibitors (abrocitinib at 100 to 200 mg daily,and upadacitinib at 15 or 30 mg daily).Dupilumab has been associated with an uncommon, reversible, benign lymphoid reaction that can mimic a cutaneous T-cell lymphoma.Cognitive behavioral therapy, even delivered over the internet, is also effective.Other traditional systemic treatments include oral prednisone (0.5 to 1 mg/kg/day), cyclosporine (3 to 5mg/kg/day), and mycophenolate mofetil (1 to 2g/day).

3.

Elsevier ClinicalKey Clinical Overview

Synopsis Atopic dermatitis/eczema is a chronic, relapsing, inflammatory disease resulting in dysfunction of the skin barrier Characterized by xerosis, pruritus, erythema, erosions, oozing, and crusting Other atopic conditions typically co-occur, including food allergies, asthma, and allergic rhinitis/rhinoconjunctivitis Diagnosis is based on patient history and physical examination and requires the finding of pruritus and eczematous skin lesions with chronic or relapsing history, typical morphology, and age-specific patterns of distribution Treatment begins with basic management of regular bathing (limited to 10-20 minutes), use of skin moisturizers immediately afterward, and avoidance of triggers (irritants), regardless of disease severity Treatment based on disease severity: Mild atopic dermatitis Basic management alone as maintenance therapy Treat flares of disease activity with lowest potency (class VII) topical corticosteroids twice daily for up to 3 days beyond flare clearance Moderate to severe atopic dermatitis Maintenance therapy with basic management plus topical antiinflammatory treatment to sites of recurrent disease, using lowest potency of corticosteroid that is effective, especially in children Medium-potency topical corticosteroid (class III or IV) applied once to twice weekly, avoiding the face and eyes Topical calcineurin inhibitor (tacrolimus [approved for moderate to severe disease] or pimecrolimus [approved for mild to moderate disease] applied 2 to 3 times weekly [daily if nonresponsive]) Treat acute flares with medium-potency corticosteroids (class III or IV) twice daily for up to 3 days beyond flare clearance

Treatment Mild atopic dermatitis is usually able to be controlled with basic management alone (as maintenance therapy) with little or no sequelae May have flares (acute worsening of symptoms) that require escalation in therapy Typically managed with lowest potency (class VII) topical corticosteroids (eg, hydrocortisone or hydrocortisone acetate [1% or less], dexamethasone); recommended to be used twice daily for up to 3 days beyond flare clearance During a flare, moisturizers may not be well tolerated on inflamed skin; however, bland petrolatum is usually tolerated Topical coal tar preparations have historically been used for mild to moderate disease, but few trials exist to determine their efficacy and they are known to cause local irritation and staining; newer preparations are more cosmetically acceptable The Joint Task Force of American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology support the use of coal tar preparations when there is scalp involvement Defined by disease that is not controlled by basic management alone and may require systemic therapies or hospitalization, or disease that has significant impact on patients life (eg, depression, anxiety, or impaired work or school performance) Maintenance therapy includes basic management (ie, bathing, moisturizers, and trigger avoidance) plus continued use of topical corticosteroids or topical calcineurin inhibitors intermittently (proactive treatment) at sites of healed dermatitis to reduce subsequent flares or relapses Proactive treatment consists of application of one of the following to flare-prone areas (areas of healed dermatitis) Medium potency topical corticosteroid (eg, triamcinolone acetonide 0.1%, mometasone furoate 0.1%) applied once to twice weekly, avoiding the face and eyes

Treatment Topical corticosteroids Class VII (lowest potency) Hydrocortisone 0.25% to 1% Hydrocortisone Topical ointment; Infants, Children, and Adolescents: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses. Hydrocortisone Topical ointment; Adults: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses. Class VI (low potency) Desonide 0.05% Desonide Topical ointment; Children† and Adolescents†: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses. Desonide Topical ointment; Adults: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses. Fluocinolone acetonide 0.01% Fluocinolone Acetonide Topical ointment; Children and Adolescents: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses. Fluocinolone Acetonide Topical ointment; Adults: Apply a thin layer topically to the affected skin area(s) 2 times daily until symptoms resolve. Proactive, intermittent application 1 to 2 times weekly to areas that commonly flare may reduce relapses.

4.

Food and Drug Administration (DailyMed).

Publish date: September 3, 2020.

Information For Patients If you get ELIDEL (pimecrolimus) Cream, 1% in any of these areas, burning or irritation can happen. Wipe off any ELIDEL (pimecrolimus) Cream, 1% from the affected area and then rinse the area well with cold water. ELIDEL (pimecrolimus) Cream, 1% is for external use only. • A patient should use ELIDEL (pimecrolimus) Cream, 1% for short periods, and if needed, treatment may be repeated with breaks in between. • Wash hands before using ELIDEL (pimecrolimus) Cream, 1%. When applying ELIDEL (pimecrolimus) Cream, 1% after a bath or shower, the skin should be dry. • Apply a thin layer of ELIDEL (pimecrolimus) Cream, 1% only to the affected skin areas, twice a day, as directed by the physician. • Use the smallest amount of ELIDEL (pimecrolimus) Cream, 1% needed to control the signs and symptoms of eczema. • A patient should not bathe, shower or swim right after applying ELIDEL (pimecrolimus) Cream, 1%. This could wash off the cream. • A patient can use moisturizers with ELIDEL (pimecrolimus) Cream, 1%. They should be sure to check with the physician first about the products that are right for them. Because the skin of patients with eczema can be very dry, it is important they keep up good skin care practices. If a patient uses moisturizers, he or she should apply them after ELIDEL (pimecrolimus) Cream, 1%.

5.

Food and Drug Administration (DailyMed).

Publish date: June 2, 2022.

Information For Patients Stop Protopic (tacrolimus) ® Ointment when the signs and symptoms of eczema, such as itching, rash, and redness go away, or as directed. Follow their doctor’s advice if symptoms of eczema return after treatment with Protopic (tacrolimus) ® Ointment. Call their doctor if: Their symptoms get worse with Protopic (tacrolimus) ® Ointment. They get an infection on their skin. Their symptoms do not improve after 6 weeks of treatment. Sometimes other skin diseases can look like eczema. To apply Protopic (tacrolimus) ® Ointment: Advise patients: Wash their hands before applying Protopic (tacrolimus) ® Ointment. Apply a thin layer of Protopic (tacrolimus) ® Ointment twice daily to the areas of skin affected by eczema. Use the smallest amount of Protopic (tacrolimus) ® Ointment needed to control the signs and symptoms of eczema. If they are a caregiver applying Protopic (tacrolimus) ® Ointment to a patient, or if they are a patient who is not treating their hands, wash their hands with soap and water after applying Protopic (tacrolimus) ® Ointment. This should remove any ointment left on the hands. Do not bathe, shower, or swim right after applying Protopic (tacrolimus) ® Ointment. This could wash off the ointment. Moisturizers can be used with Protopic (tacrolimus) ® Ointment. Make sure they check with their doctor first about the products that are right for them. Because the skin of patients with eczema can be very dry, it is important to keep up good skin care practices. If they use moisturizers, apply them after Protopic (tacrolimus) ® Ointment. What should patients avoid while using Protopic (tacrolimus) ® Ointment? Advise patients: Do not use ultraviolet light therapy, sun lamps, or tanning beds during treatment with Protopic (tacrolimus) ® Ointment.

6.

Food and Drug Administration (DailyMed).

Publish date: November 3, 2023.

Precautions However, a link with tacrolimus ointment has not been shown. Because of this concern, instruct patients: • Do not use tacrolimus ointment continuously for a long time. • Use tacrolimus ointment only on areas of skin that have eczema. • Do not use tacrolimus ointment on a child under 2 years old. Tacrolimus ointment comes in two strengths: • Only tacrolimus ointment 0.03% is for use on children aged 2 to 15 years. • Either tacrolimus ointment 0.03% or 0.1% can be used by adults and children 16 years and older. Advise patients to talk to their prescriber for more information. How should tacrolimus ointment be used? Advise patients to: • Use tacrolimus ointment exactly as prescribed. • Use tacrolimus ointment only on areas of skin that have eczema. • Use tacrolimus ointment for short periods, and if needed, treatment may be repeated with breaks in between. • Stop tacrolimus ointment when the signs and symptoms of eczema, such as itching, rash, and redness go away, or as directed. • Follow their doctor's advice if symptoms of eczema return after treatment with tacrolimus ointment. • Call their doctor if: ∘ Their symptoms get worse with tacrolimus ointment. ∘ They get an infection on their skin. ∘ Their symptoms do not improve after 6 weeks of treatment. Sometimes other skin diseases can look like eczema. To apply tacrolimus ointment: Advise patients: • Wash their hands before applying tacrolimus ointment. • Apply a thin layer of tacrolimus ointment twice daily to the areas of skin affected by eczema. • Use the smallest amount of tacrolimus ointment needed to control the signs and symptoms of eczema. • If they are a caregiver applying tacrolimus ointment to a patient, or if they are a patient who is not treating their hands, wash their hands with soap and water after applying tacrolimus ointment.