Pillar 3: Therapeutic measures
Goals of Eczema management
The overall goals of treatment are two-fold:
- Long-term management: to reduce the severity and frequency of flares.
- Flare management: During a flare, the immediate goal is to reduce itching and heal the skin.
Discussing therapeutic measures with your doctor
You can help your doctor make the best treatment decision for you by asking questions and telling him or her key information about your eczema.
When you go to see your doctor, it is important to make the most of every visit. In the time between appointments, write down questions about eczema and your treatment as they occur to you, so nothing will be forgotten when you meet with your doctor. To get you started, here is a list of suggested questions for your doctor.
Suggested questions to ask your doctor
- What results should I expect from the therapy you have prescribed?
- Will the itch decrease?
- Will I have fewer flares?
- Will my quality of life improve?
- Why did you prescribe this therapy and not another?
- What are the side effects of the treatment you have prescribed to me?
- If side effects happen, what should I do?
- Since I last saw you, I have experienced the following symptoms (list your symptoms along with the dates and circumstances). What can I do about these symptoms?
- Other than medicate, what else can I do?
Early signs and symptoms
Treating the first itch or other sign that an eczema flare is coming up early can help to prevent a flare from happening. You may not notice the first signs or may be afraid to use your medication because you are afraid of side effects. Ask your health care professional about how to identify the first signs and the side effects of the medication you have been prescribed.
Check your skin every day for first signs and symptoms
Itch often happens before there are any visible signs of eczema on the skin. Other first signs include a tingling sensation, whitening, a tiny bump or a bit of redness. If scratching occurs at this stage, development of a flare is more likely.
Treat early signs and symptoms according to your doctor’s instructions
Your doctor may prescribe one or more topical (i.e., applied to the skin) medications to treat the early signs and symptoms of eczema. Two commonly prescribed medications are:
- Topical calcineurin inhibitors (TCIs)
- Topical corticosteroids (TCSs)
It is important to use these products exactly as your doctor tells you, including how much and how long. The medications and/or medication schedule to treat a flare may be the same as or different from the medications to treat the first signs and symptoms of eczema. Don’t be afraid to ask your doctor for clarification if you are not sure.
Treating flares
A flare can be a difficult experience. During a flare, the affected part of the skin becomes red and extremely, uncontrollably itchy. Since it is almost always scratched, the skin tends to be broken and can be oozing and crusted. With time, the skin can redden, swell, crack, weep, scale and become markedly thick and hardened.
During a flare, it is important to stay calm and use the medications your doctor has prescribed to you.
Your doctor may prescribe one or more topical (i.e., applied to the skin) medications to treat the early signs and symptoms of eczema.
Two commonly prescribed medications are:
It is important to use these products exactly as your doctor tells you, including how much and how long. The medications and/or medication schedule to treat a flare may be the same as or different from the medications to treat the first signs and symptoms of eczema. Don’t be afraid to ask your doctor for clarification if you are not sure.
Topical corticosteroids
Use
Topical corticosteroid products are commonly prescribed to treat eczema early signs and symptoms and flares. TCSs are indicated for the treatment of acute and chronic skin eruptions, where anti-inflammatory, anti-allergenic and anti-itch action is needed.
Treatment with topical corticosteroids should:
- Reduce symptoms of itchiness, redness and thus the urge to scratch
- Clear the skin within a certain period of time (e.g., 10 to 14 days)
If you do not see results with the corticosteroid after using it for 10 to 14 days, you may be referred to a dermatologist for further assessment. Topical corticosteroids may be prescribed to be used with other treatments, including topical calcineurin inbibitors. Topical corticosteroids are classified based on strength from mild to extremely potent.
TCSs in Canada
| Generic Name | Brand Name(s) |
| Hydrocortisone | Cortoderm® (Taro) Emocort® (TCD) Hydrosone® (Rougier) Sama-HC® (Stiefel) Vioform® (Paladin) |
| Hycrocortisone acetate | Cortef® cream (McNeil) Hyderm® (Taro) Uremol HC® (TCD) |
| Methylprednisolone | NA |
| Methylprednisolone acetate | NA |
NA = Not Available |
|
| Generic Name | Brand Name(s) |
| Clobetasone 17-butyrate | Spectro® (GlaxoSmithKline) |
| Desonide | Desocort® (Galderma) |
| Flumethasone pivalate | Locacorten Vioform® (Paladin) |
| Fluticasone propionate | Cutivate® (GlaxoSmithKline) |
| Hydrocortisone valerate | Hydroval® (Taro) Westcort® (Squibb) |
| Prednicarbate | Dermatop® (sanoli-Aventis) |
| Triamcinolone acetonide | Triamderm® (Taro) Aristocort® (Valeo Pharma) |
| Generic Name | Brand Name(s) |
| Amcinonide | Cyclocort® (Stiefel) Ratio-amcinonide® (Ratiopharm) Taro-amcinonide® (Taro) |
| Betamethasone valerate | Betaderm® (Taro) Celestoderm V and V/2® (Schering) Ratio-Ectosone® (Ratiopharm) Valisone G® (Schering) |
| Desoximetasone | Topicort® (Sanofi-Aventis) |
| Diflucortolone diacetate | NA |
| Fluocinolone acetonide | NA |
| Fluocinonide | NA |
| Halcinonide | NA |
| Mometasone furoate | Ratio-mometosone® (Ratiopharm) Taro-mometosone® (Taro) Elocom® (Schering) |
NA = Not Available |
|
| Generic Name | Brand Name(s) |
| Betamethasone dipropionate | Diprolene Glycol® (Schering) Diprosalic® (Schering) Diprosone® (Schering) Ratio-topisone® (Ratiopharm) Taro-Sone® (Taro) |
| Clobetasol 17-propionate | Dermovate® (Taro) Gen-clobetasol® (GenPharm) Taro-clobetasol |
| Halobetasol propionate | Ultravate® (Sqibb) |
Safety Profile
Steroids must be used carefully to avoid side effects. Topical corticosteroids are traditionally used to treat flares although their long-term use is limited by skin level complications such as skin thinning, lines and visible dilation of blood vessels.
Prolonged exposure of your skin to corticosteroids can result in:
- Easy bruising
- Thinning of the skin
- Increased skin fragility
- Increased infection risk
The overuse of corticosteroids can thin the skin and make it more vulnerable to irritants and allergens, and ultimately to more eczema symptoms and flares.
Topical calcineurin inhibitors
Use
Topical calcineurin inhibitors (TCIs) are non-steroidal anti-inflammatory prescription agents that can be used to treat the symptoms of eczema. Two TCIs are available in Canada, one for mild to moderate eczema and the other for moderate to severe disease. TCIs may be prescribed in combination with topical corticosteroids.
TCIs in Canada
| Category | Generic Name | Brand Name(s) |
| For mild eczema | Pimecrolimus | ELIDEL® (Novartis/Galderma) |
| For moderate eczema | Pimecrolimus Tacrolimus |
ELIDEL® (Novartis/Galderma) Protopic® (Astellas Pharma) |
| For severe eczema | Tacrolimus | Protopic® (Astellas Pharma) |
Safety profile
TCIs have been associated with a risk of cancer and application-site burning.
Other therapy
At the physician’s discretion, the following agents may be used to supplement TCS or TCI treatment:
- Antihistamines: mainly help to control eczema associated itching
- Anti-infective agents: to reduce risk of infection
- Wet compresses
Antihistamines
Oral antihistamines can be used to control eczema-associated itching, and thus reduce the likelihood that patients will scratch and cause further damage. Antihistamines are especially useful for patients who experience poor sleep due to itching.
Anti-infective agents
The skin of people with eczema often gets infected. When scratching breaks the skin, microbes can enter. Since skin in a person with eczema is very dry, it also cannot stop microbes from getting through as much as normal skin can.
Your doctor will prescribe medication for the infection. It is very important that you use that medication and clear it up because infection just makes eczema worse.
Wet compresses
Wet compressing eczema lesions can help to retain moisture, hydrating the skin and preventing further flares. This technique can also help improve medication penetration into the skin.