Atopic Eczema Treatment

Atopic eczema, also called atopic dermatitis, is a chronic, relapsing inflammatory skin disorder that occurs on a background of atopy.

• There is often a personal or family history of atopic diseases such as:

  • Asthma

  • Allergic rhinitis (hay fever)

  • Atopic dermatitis

• The disease is characterized by intense pruritus, xerosis (dry skin), and eczematous lesions that vary with age.

• Eczema is often triggered or exacerbated by environmental factors, allergens, irritants, infections, or stress.

Clinical Forms and Diagnostic Criteria

Atopic eczema can present differently depending on the patient’s age and disease stage.

Infantile Eczema (“Milk Crust”)

• Usually appears around 3 months of age

• Lesions are oozing, crusted, and typically involve:

  • Cheeks

  • Forehead

  • Scalp

Important: If generalized exfoliative dermatitis develops, refer to a higher-level facility for specialist care.

Flexural Eczema

• Onset around 3–4 years of age

• Predominantly affects flexural surfaces:

  • Elbows

  • Knees

  • Nape of the neck

• Features include:

  • Thickening and lichenification

  • Intense pruritus, often worse at night

Note: Eczema may evolve through three stages:

1. Acute – weeping lesions

2. Subacute – crusted lesions

3. Chronic – lichenified, scaly skin

Signs & Symptoms

• Intense itching (pruritus)

• Erythema and inflammation

• Oozing or crusted lesions (in acute phase)

• Lichenification and hyperpigmentation (in chronic phase)

• Xerosis (dry, rough skin)

• Secondary infections (bacterial, viral, or fungal)

• Excoriations due to scratching

Investigations

Routine investigations are usually not required, but may be considered in complicated or atypical cases:

• Skin swab for bacterial culture (if secondary infection suspected)

• Patch testing for contact allergens

• IgE levels in severe or atypical presentations

• Skin biopsy (rarely) if diagnosis is uncertain

Treatment

Management of atopic eczema is multimodal, involving non-pharmacological and pharmacological strategies.

Non-Pharmacological Treatment

• Patient Education: Explain chronic nature, triggers, and importance of adherence

• Avoid Triggers:

  • Skin irritants (soaps, detergents, wool, harsh cleansers)

  • Extreme temperatures

  • Allergens

• Emollients:

  • Generous use of skin moisturizers (emulsifying ointments, aqueous creams)

  • Bath oils or soap substitutes

• Bathing Practices:

  • Short lukewarm baths

  • Avoid prolonged soaking or harsh scrubbing

Pharmacological Treatment

Antihistamines (for pruritus)

• Promethazine (PO) 25 mg at bedtime; increase to 50 mg if necessary, for 2 weeks.

OR

• Cetirizine (PO) 10 mg once daily for 2 weeks.

OR

• Loratadine (PO) 10 mg once daily for 2 weeks.

Topical Corticosteroids

Mild disease or lesions on the face:

• Hydrocortisone 1% ointment (topical): Apply every 12 hours.

OR

Other parts of the body:

• Betamethasone valerate cream/ointment (topical) 0.1% or 0.25%: Apply every 12 hours.

OR

Severe cases:

• Clobetasol propionate cream/ointment (topical) 0.05%: Apply every 12 hours for up to 8 weeks.

OR

• Tacrolimus ointment (topical) 0.03% or 0.1%: Apply every 12 hours for not less than 1 month.

In case of skin atrophy on the face and in children >1 year:

• Prednicarbate cream (topical) 0.1%: Apply once daily.

Severe Cases (Erythroderma – Extensive involvement of the whole body)

• Patient needs admission.

• Oral antibiotics as for impetigo.

• Prednisolone (PO) 0.5–1 mg/kg once daily for 1–2 weeks, then taper.

Recalcitrant Cases

• Methotrexate (PO) 7.5–20 mg once weekly for not less than 3 months.

OR

• Cyclosporine 3–5 mg/kg/day for up to 3 months.

Phototherapy

• Phototherapy may be considered for appropriate patients.

Management of Skin Lesions

Treat any infection (usually bacterial, but occasionally viral, e.g., eczema herpeticum).

Choice of skin preparations depends on whether lesions are wet (exudative) or dry/lichenified (thickened skin with increased skin markings).

If eczema is weepy:

• Potassium permanganate 1:4000 (0.025%) solution: Apply once daily for 2–4 days until dry.

• Where large areas are involved, give a course of antibiotics for 5–10 days (as for impetigo).

After the lesions have dried:

• Apply an aqueous cream for a soothing effect.

• Start with a mild topical steroid cream for wet lesions and use an ointment for dry skin lesions.

If the skin becomes chronic (lichenified/scaling):

• Add an emollient such as emulsifying ointment or liquid paraffin.

Notes

• Potent topical corticosteroids may cause harmful cutaneous and systemic adverse effects, especially with prolonged use or application to extensive body surface areas.

• Adverse effects include striae, acne, hyperpigmentation, hypopigmentation, hirsutism, and skin atrophy.

• Avoid long-term use of potent topical corticosteroids.

• Do not apply potent topical corticosteroids to weepy or infected skin.

• Advise patients not to use potent topical corticosteroids for cosmetic purposes (e.g., skin lightening).

Classes of Topical Steroids

• Very Potent: 0.05% Clobetasol propionate

• Potent: 0.1% Betamethasone valerate

• Diluted Potent: 0.025% Betamethasone valerate

• Moderately Potent: 0.05% Clobetasol butyrate

• Mild: 1% Hydrocortisone

Caution: Long-term or extensive use may cause:

• Striae

• Acne

• Hyperpigmentation or hypopigmentation

• Skin atrophy

• Hirsutism

Patient education: Avoid use as cosmetic for skin lightening.

Prevention

• Consistent use of emollients

• Avoid known irritants and allergens

• Maintain regular bathing and skin care routines

• Early treatment of infections

• Avoid scratching (use gloves for infants at night if needed)

Complications

• Secondary bacterial infection (Staphylococcus aureus)

• Viral infections (eczema herpeticum)

• Lichenification and permanent hyperpigmentation

• Sleep disturbance due to nocturnal pruritus

Prognosis

• Chronic and relapsing; severity may reduce with age

• Proper skin care and trigger avoidance improves quality of life

• Severe cases may require specialist dermatology car