Eczema is an incurable skin condition associated mainly with dry and itchy skin, so successful treatment of it relies heavily on the management of symptoms. First-line treatment options common to all severities of the condition includes the use of unperfumed moisturisers, in conjunction with short-term topical corticosteroid use to control flare-ups. Additional treatments are recommended as the severity of eczema increases.
Eczema management plan
A good skincare routine is essential for any kind of eczema. If eczema is not treated appropriately and timely, the skin may become even more irritated and itchy, leading to more scratching and damage. A management plan based on best practice¹ should involve the following: identifying and avoiding known triggers and irritants, maintaining and protecting skin every day, treating flares and controlling itch and preventing infection¹⁻³.T herefore, the main goals of such eczema management plan are: (a) to identify and minimise exposure to factors that aggravate eczema, (b) to maintain the barrier function of the skin with moisturisers and (c) to use anti-inflammatory (topical corticosteroids) and any other required treatment to control aggravation (Table 1)¹⁻³.
Table 1: Recommended treatment options for the different severities of eczema. Moisturiser therapy is recommended for each severity, as is anti-inflammatory topical corticosteroid therapy (adjusted for severity). Additional treatment options such as wet bandages and medications are recommended as the severity of eczema increases¹⁻³.
Identifying and avoiding known triggers and irritants
Common factors that worsen eczema include dry skin, heat and sweating, low humidity, emotional stress and irritants such as soaps, detergents and some fabrics (e.g. wool) as well as infection² ⁴. People with eczema should avoid using harsh soaps and detergents or bubble bath. Instead, soap substitutes such as wash products, namely, cleansers and bath oils that generally contain no preservatives, irritants, fragrance or colour can be used² ⁵ ⁶.
Maintaining and protecting skin every day. Moisturise, moisturise, moisturise...
The aim of using moisturisers liberally, frequently and continuously is to maintain the skin’s barrier function to keep moisture in, and irritants, allergens and pathogens out² ⁴. Most people with eczema have dry skin which generally causes itch and also contributes to formation of cracks in the skin, through which irritants and pathogens can enter² ⁸. Since moisturisers are universally recommended as the first-line treatment for eczema, application of moisturisers two to four times daily (or as required), best applied after bathing or showering while the skin is hydrated, is ideal. For most people regular once-a-day application is achievable and can still lead to improved outcomes. Moisturisers are available as lotions, creams and ointments. Generally speaking, lotions are suitable for normal and dry skin, creams are suitable for moderately dry skin, while ointments are suitable for very dry skin. The best moisturiser is the one preferred by the patient because it is more likely to be used regularly.² ⁸
Despite efforts to avoid irritants and the best use of moisturisers, flares are characteristic of eczema. Topical corticosteroids are the main agents used to control flares. As the intention is to use them short-term, they should be applied in appropriate amounts to all affected areas to gain rapid control. In general the potency of a corticosteroid should be matched to the severity of the flare. For mild flares use a mild corticosteroid, for a moderate flare use a moderately potent corticosteroid and for a severe flare use a potent corticosteroid (Table 1). Treatment should continue until the flare has resolved. In most cases, once control of a flare is achieved, corticosteroids can be stopped. However, for those who experience frequent flares it may be useful to continue topical corticosteroids between flares if advised to do so by a healthcare professional. Also, it is very important to continue the use of moisturisers during flares and for regular skin maintenance as well² ³.
The corticosteroid chosen should also be the least potent option available to manage eczema. Prolonged topical corticosteroid use should be avoided to limit the risk of adverse effects such as thinning of the skin⁹.
Controlling itch and preventing infection
Itch associated with eczema can cause scratching, bleeding and infection. During a flare, the itch can result in significant sleep loss for which a short course of sedating antihistamine may be useful² ⁵.
Wet bandages are used to hydrate the skin and prevent itching, scratching, inflammation and soreness by cooling. They can also enhance penetration of topical steroids into the skin. They can be effective for moderate, severe or extensive eczema. Wet bandages are typically used overnight and removed in the morning. Moisturisers should continue to be applied frequently throughout the day to the affected areas. Wet bandages may be used for a few nights (maximum five to seven consecutive nights) until the redness, swelling and weeping has settled down² ⁵ ¹⁰.
Eczema lesions are commonly colonised with the bacteria. For localised areas of infection a topical antibiotic may be used either in conjunction with a corticosteroid or as a combined product² ⁵. Additionally, antiseptics can be used to reduce bacterial load in infection-prone areas² ³.