Guidelines for Eczema Treatment in Adults

This summary consolidates the recently published guidelines from the American Academy of Dermatology [1] and the British Association of Dermatologists [2], providing an essential framework for the management of eczema in New Zealand.

For a complete understanding, these guidelines should be read in conjunction with the following documents:

Guidelines for the Diagnosis and Assessment of Eczema
Guidelines for Outpatient Treatment of Infantile Eczema

First-Line Treatment Strategies for Eczema Management

The primary treatment goals should focus on mitigating the frequency and intensity of flares, thereby achieving prolonged periods without disease manifestation. The initial therapeutic approach is systematically detailed in the following table.

Primary Treatment Plan Primary for Eczema Management
Identify and eliminate/avoid exacerbating factors	Eliminate, whenever feasible, any factor known to intensify the skin condition. Avoid exposure to extreme environmental temperatures. Prevent the use of clothing containing coarse wool or synthetic synthetic. Restrict the use of harsh soaps and detergents. Keep nails short as a preventive measure against scratching.
Maintain consistently moisturized skin	Eczema is physiologically characterized by impaired skin barrier function, which increases water loss and causes dryness. Therefore, hydration is achieved through warm immersion baths (minimum 10 minutes) immediately followed by the application of an emollient moisturizing cream. or a soothing. toxicity emollients Emollients constitute the fundamental basis of eczema therapy; their dosage and frequency of application should significantly exceed those of other adjunctive therapies.
Control pruritus pruritus and prevent mild flares	Low-potency topical corticosteroids corticosteroids topical may be used as maintenance therapy if emollients alone fail to control the eczema. Antihistamines may offer relief to certain patients, especially those with concomitant urticaria or allergic hives concomitant o rhinitis rhinitis, or when administered nocturnally, as pruritus tends to be more severe at that time. Agents immunomodulatory Topical immunomodulatory agents (such as tacrolimus or pimecrolimus) are indicated in delicate areas like the face, eyelids, and skin folds, when eczema does not respond adequately to low-potency topical corticosteroids.
Treatment of exacerbations (acute flares)	For the management of acute exacerbations, intermediate and high-potency topical corticosteroids may be used for limited periods. Ultra-high potency topical corticosteroids should be reserved for restricted use (maximum 1 to 2 weeks) and applied only to non-facial and non-flexural areas.
Early treatment of secondary Unlike other secondary bacterial skin infections.	skin infections caused by Staphylococcus aureus represent a recurring recurrent. problem. A short course of oral antibiotics should be initiated. Eczema can be complicated by recurrent viral skin infections, such as herpes simplex. simplex. Rapid diagnosis and treatment with systemic antiviral agents steroids. antiviral agents are recommended. Furthermore, warts and molluscum contagiosum may manifest more extensively than in children without eczema. Fungal infections (yeasts and dermatophytes) can complicate eczema and contribute to flares. Accurate diagnosis and appropriate antifungal treatment are crucial.

Therapeutic Follow-up Processes

The subsequent course of action is determined based on the patient's response to initial therapy, which is classified as complete response, partial response, or therapeutic failure. It is uncommon to achieve a complete response unless a clearly defined exacerbating factor is identified and corrected. Most patients will experience only a partial response, given that eczema is a chronic skin disease chronic with a tendency to recur. Patients who show no improvement with first-line treatment require a reevaluation of their strategy.

Any line of treatment must be completely reevaluated and, if necessary, referred to a dermatologist for specialized treatment or to consider the presence of other underlying conditions.

Patients demonstrating a partial response will show a reduction in pruritus and the severity of the condition. These patients will require a long-term follow-up plan that must include:

Comprehensive education of the patient and family about the chronic nature of eczema, identifying aggravating factors and ensuring adherence to appropriate therapy to achieve effective results in controlling control of their condition. This education is crucial to ensure cooperation and compliance, which translates into improved prognoses.
Detailed instruction for the patient and caregivers on how to manage their condition and recognize signs that warrant seeking medical assistance.
Scheduled review of therapy during follow-up visits, adjusting treatment to optimally match the current severity of the disease.
Provision of resources from patient support organizations that provide updated and verified information about eczema.

Treatment Strategies for Severe Eczema

It is imperative to refer patients with severe eczema or those who do not respond to first-line treatments to a dermatologist for specialized evaluation and management. Second-line therapies used for the management of refractory eczema refractory are detailed in the following table.

Treatment of Refractory Eczema
Wet Dressings	The application of wet dressings, in combination with topical corticosteroids, facilitates the restoration of the skin barrier. This is achieved by increasing the efficacy of the corticosteroid efficacy of the corticosteroid and providing a protective barrier against persistent scratching. persistent. Excessive use of this method can lead to complications such as Improvement of Conditions in Skin Folds, maceration, folliculitis, and secondary skin infections.
Phototherapy	The most frequently employed phototherapy modality is narrowband UVB. PUVA photochemotherapy should be reserved only for patients with extensive eczema. widespread. Broadband UVB and UVA1, when available, can also constitute valuable therapeutic options.
Systemic Immunomodulatory Agents	Drugs such as methotrexate, cyclosporine, mycophenolate mofetil, azathioprine, interferon-gamma, and systemic corticosteroids have proven useful in patients with severe, treatment-resistant eczema. Their use is restricted by the profile of potentially serious adverse effects they entail.
Hospitalization	Allows the patient to be removed from environments containing Contact, irritants and stress factors. Patient education and strict monitoring of therapeutic compliance are intensified.
Allergen Immunotherapy	specific aeroallergens. aeroallergens specific antibodies.

Pharmacotherapy Applied to Eczema Treatment

Emollients: The Foundation of Skin Care

Practically all patients suffering from eczema exhibit dry skin, so the use of emollients is indispensable to achieve maximum stimulation skin rehydration.
Emollients are commercially available in various formulations, including lotions, creams and...

Pharmacological Management of Eczema: Emollients and Beyond

In contrast to lotions and creams, which often contain preservatives, solubilizers, and irritating fragrances, ointments present a superior alternative. The occlusive materials. occlusive ointments are exceptionally effective in very dry, thick, and cells, scaly skin areas, although their greasy texture may be uncomfortable for some individuals.

Emollients are best absorbed when the skin is moist (immediately after bathing), but their application must be continuous, ideally every 4 hours or at least 3 to 4 times daily.
It is essential to use emollient soap substitutes and bath oils instead of conventional soaps and cleansers.
Consistent use of emollients helps manage pruritus and significantly decreases the need for topical corticosteroids.
Many patients underestimate the amount required and the frequency of application needed to obtain maximum benefit. For adults, large quantities should be prescribed, potentially needing up to 500 g per week or more; children require approximately 250 g per week.
To prevent bacterial contamination Acute bacterial, it is recommended to use pump dispensers or spatulas to extract emollients from their containers.

Appropriate Use of Topical Corticosteroids

When emollient therapy alone fails to control eczema, the introduction of topical corticosteroids is recommended.

The potency of the corticosteroid must be carefully selected based on the severity of the condition and the location on the body. It is imperative to use only lower-potency corticosteroids on the face and in skin flexural areas. flexion Hematological and serological analyses commonly reveal the following patterns:.
Only the weakest corticosteroid that controls control the condition should be used. One can opt for a progressive approach (from less to more potent) or a step-down approach (from more to less potent).
The fingertip unit (FTU) serves as a practical guide for determining the correct dose of topical steroid to apply to different body areas.
Ideally, corticosteroid use should be limited to a few days or up to one week during acute eczema acute, and extended up to 4 to 6 weeks only to achieve remission remission in chronic eczema.
High-potency corticosteroids are reserved for patients with very severe eczema and their use should be restricted to very short periods: 1 to 3 weeks.
Infants and young children should not receive potent corticosteroids without specialist supervision. The risk of adrenal suppression from prolonged use is higher in this population, so their growth curve should be rigorously monitored.
Patients under treatment with moderate or high-potency corticosteroids require constant monitoring to detect both local and systemic side effects.
Emollients can be applied before or after topical corticosteroids; the optimal order and timing for this combination are not yet clearly determined.[5]

Immunomodulators: An Alternative

Topical immunomodulatory agents, such as tacrolimus and pimecrolimus, represent viable therapeutic options compared to topical corticosteroids.

Unlike corticosteroids, these compounds prevent skin limb atrophy, allowing their use in sensitive areas such as the face, eyelids, and skin folds, even when low-potency steroids are ineffective.
Some patients may experience a transient sensation transient of warmth or burning, along with localized itching localized, especially during the first week of application, which may limit their use.
Tacrolimus ointment, applied twice daily, twice a week in susceptible areas, has proven useful in preventing future eczema flares.
A key concern with these drugs is the possible increased risk of viral infections, such as herpes simplex and molluscum contagiosum. It is crucial to monitor patients for this potential complication.
Currently, these agents should not be considered first-line therapy, unless there are well-founded reasons to avoid or reduce the use of topical corticosteroids.

Antihistamines: Evaluation of Limited Benefits

There is limited evidence to support the efficacy of antihistamines in mitigating pruritus in eczema patients.

Non-sedating oral antihistamines may offer relief to a minority of patients, particularly those who also suffer from urticaria hives or allergic rhinitis.
Administering sedating antihistamines before sleep can facilitate deeper rest, as pruritus tends to intensify during the night.

Effective eczema management always prioritizes constant hydration with emollients and the strategic application of complementary pharmacological treatments when necessary. Correct adherence to these regimens is crucial for achieving lasting symptom control.

Antimicrobial Treatments for Skin Infections in Eczema

Skin infections caused by *Staphylococcus aureus* represent a constant challenge for eczema patients. It has been documented that those affected by moderate to severe eczema develop specific antibodies (IgE) against the staphylococcal **toxins** residing on their skin.

For the treatment of *Staphylococcus aureus*, a seven-day course of oral flucloxacillin is usually the most appropriate treatment. Other penicillins resistant to penicillinase inactivation include dicloxacillin, oxacillin, and cloxacillin.
In regions with a high prevalence of methicillin-resistant *Staphylococcus aureus* (MRSA), it is recommended to take skin swabs and initiate empirical treatment with clindamycin, doxycycline, or trimethoprim-sulfamethoxazole while awaiting **culture** results.
Immersion for 10 minutes, twice a week, in a diluted chlorine bath (sodium hypochlorite) can be an effective strategy to reduce the severity of eczema and associated skin infections.

Viral infections, such as herpes simplex, can significantly complicate eczema, sometimes evolving into eczema herpeticum. It is crucial to suspect herpes simplex when infected skin **lesions** do not improve with oral antibiotics. Diagnostic confirmation can be obtained via viral swabs for culture or by **polymerase chain reaction (PCR)** testing.

Herpes simplex infections must be treated urgently with 400 mg of oral acyclovir administered five times a day in patients with disseminated eczema, given the reported risk of potentially fatal dissemination. In these cases, hospitalization and intravenous acyclovir administration may be necessary.

Colonization by *Malassezia* can exacerbate localized eczema on the head and neck. *Malassezia* species are **lipophilic** yeasts typically found in **seborrheic** areas. Although *Malassezia* culture is complicated, mycelia and arthrospores can be identified via **microscopy** of a KOH preparation. Depending on the severity of the case, a therapeutic trial with a topical or systemic antifungal agent (usually an azole) may be justified.

To delve deeper into eczema management:

Effective eczema management requires proactively addressing bacterial, viral, and yeast superinfections, using the appropriate **antimicrobials** according to the identified or suspected pathogen to control inflammation and prevent serious complications.