Eczema (Atopic Dermatitis) Treatment: A Stepwise Approach

Management Principles

Eczema is a chronic, relapsing inflammatory skin condition. Treatment follows a stepwise algorithm based on severity:

Foundation for All Severities

• Emollients (moisturizers): Apply ≥2× daily, especially after bathing. Ointments > creams > lotions. Fragrance-free, ceramide-containing preferred.
• Trigger avoidance: Irritants (soaps, detergents, wool), allergens (dust mite, pet dander), heat/sweat, stress.
• Bathing practices: Lukewarm, ≤10 min, gentle cleanser, pat dry, moisturize within 3 min.

Mild Flares

• Low-potency topical corticosteroids (TCS): hydrocortisone 1–2.5% (face/folds), desonide 0.05%
• Topical calcineurin inhibitors (TCI): tacrolimus 0.03%, pimecrolimus 1% – steroid-sparing for face/folds/maintenance
• Crisaborole 2% ointment (PDE4 inhibitor) – non-steroidal alternative

Moderate Flares

• Mid-potency TCS: triamcinolone 0.1%, fluocinolone 0.025%, mometasone 0.1%
• Short courses (2 weeks), then taper to proactive maintenance (weekend-only TCS/TCI)

Severe/Refractory Disease

• High-potency TCS (short-term, non-facial): clobetasol 0.05%, betamethasone dipropionate 0.05%
• Phototherapy: NB-UVB (narrowband UVB) 2–3×/week
• Systemic agents (specialist-managed):

Agent	Mechanism	Monitoring
Dupilumab	IL-4Rα antagonist (biologic)	CBC, eosinophils, conjunctivitis
Upadacitinib / Abrocitinib	JAK1 inhibitors (oral)	CBC, LFTs, lipids, TB screen, VZV vaccine
Cyclosporine	Calcineurin inhibitor	Renal function, BP, lipids, Mg, drug levels
Methotrexate	Antimetabolite	CBC, LFTs, renal, pulmonary, folate
Azathioprine / Mycophenolate	Antimetabolites	CBC, LFTs, TPMT (aza)

When to See a Specialist

• Inadequate response to mid-potency TCS after 2 weeks
• Frequent flares requiring repeated potent TCS
• Suspected contact allergy (patch testing)
• Quality of life significantly impacted
• Need for systemic therapy