Atopic eczema - Treatment 

Treating atopic eczema 

Infected eczema is often sore, very red and oozing, and is usually treated with antibiotics 

Complementary therapies

Some people use complementary therapies such as food supplements or herbal remedies to treat atopic eczema. Although some people may find these therapies helpful, there is a lack of evidence to show they are effective in treating atopic eczema.

If you are thinking about using a complementary therapy, speak to your GP first to ensure the therapy is safe for you to use. For example, some herbal treatments can cause serious side effects in the liver and may require blood tests for monitoring. You should continue to use other treatments your GP has prescribed.

Compare your options

Take a look at a simple guide to the pros and cons of different treatments for eczema

Although there is no cure for atopic eczema, treatments can ease the symptoms.

Children with atopic eczema normally find their symptoms naturally improve over time.

Medications used to treat atopic eczema most commonly include:

Your GP will prescribe emollients for dry skin and the weakest effective topical corticosteroid. Different strengths are needed for different parts of the body.

As long as the eczema is not infected, certain dressings or bandages – known as dry wraps, wet wraps and occlusive dressings – may also be applied by a healthcare professional.

They work by reducing itchiness, preventing scratching and helping to stop the skin from drying out.

Other medications

Other medicines used to ease the symptoms of eczema include:   

  • antihistamines for severe itching 
  • oral corticosteroids for severe symptoms
  • antibiotics for infected eczema  
  • topical immunosuppresants, which reduce or suppress your body's immune system, such as pimecrolimus cream and tacrolimus ointment

Your GP will prescribe additional medication as and when it is needed.

Self-care

As well as medication, there are things you can do yourself at home to help ease symptoms. 

Scratching

Eczema is often itchy and scratching it can aggravate the skin, eventually causing it to thicken. Scratching your skin also increases the risk of your eczema becoming infected with bacteria. 

Read more about complications of atopic eczema.

There may be times when you or your child cannot help scratching. Keeping nails short will minimise damage to the skin. 

If your baby has atopic eczema, anti-scratch mittens may stop them scratching their skin. Tapping or pinching the skin until the itch has gone may also offer relief.

Avoiding triggers

Your GP will work with you to establish what might trigger the eczema flare-ups, although it may get better or worse for no obvious reason.

Once you know what triggers a flare-up, you can try to avoid them. For example:

  • if certain fabrics irritate your skin, avoid wearing these and stick to natural materials such as cotton
  • if heat aggravates your eczema, keep the rooms in your home cool
  • avoid using soaps or detergents that may affect your skin

Although many people with eczema are allergic to house dust mites, it is not recommended that you try to get rid of them from your home. The process is time consuming and difficult to carry out effectively, and there is no clear evidence that it helps.

Similarly, although living in an area that has hard water is associated with slightly higher levels of eczema in younger children, installing a water softener does not seem to make any difference.

Diet

You should not make any significant dietary changes without first speaking to your GP. Some foods, such as milk, eggs and nuts, have been shown to trigger eczema symptoms. 

However, it may not be healthy to cut these from your diet without medical advice, especially in young children who need plenty of the calcium, calories and protein that are provided by these foods.

If your GP suspects you have a food allergy, you may be referred to a dietitian (a specialist in diet and nutrition).

If you are breastfeeding a baby with atopic eczema, get medical advice before making any changes to your regular diet.

Emollients

Emollients are substances that help soften your skin to keep it moist. They reduce water loss from the skin by covering it with a protective film. They are the most important treatment for dry skin associated with atopic eczema.

It is important to keep skin moisturised to prevent it becoming dry and cracked.

Choosing an emollient

There are several different emollients available, some of which you can buy over-the-counter without a prescription. Your GP or pharmacist can recommend a suitable one for you, although you may need to try a few before you find one that suits you.

You may also be prescribed different emollients for different uses, such as:

  • an ointment for very dry skin 
  • a cream or lotion for less dry skin
  • an emollient to use on your face and hands 
  • a different emollient to use on your body  
  • an emollient to use instead of soap 
  • an emollient to add to bath water or use in the shower

The difference between lotions, creams and ointments is the amount of oil and water they contain. Ointments contain the most oil so can be quite greasy, but they are the most effective at keeping moisture in the skin. Lotions contain the least oil so are not greasy, but can be less effective. Creams are in the middle.

If you have been using a particular emollient for some time, it may eventually become less effective or may start to irritate your skin. If this happens, speak to your GP as another product can be prescribed instead.

If the skin is inflamed, emollients should be used along with an anti-inflammatory treatment, such as topical corticosteroids.

How to use emollients

Use your emollient all the time, especially between flare-ups, even when you do not have symptoms. Keeping separate supplies of emollients at work or at school can be a good idea.

To apply the emollient:

  • use a large amount
  • smooth the emollient into the skin in the same direction that the hair grows
  • do not rub the emollient in
  • for very dry skin, apply emollient every two to three hours
  • after a bath or shower, gently dry the skin and apply the emollient while the skin is still moist
  • do not share emollients with other people
  • do not put your fingers into an emollient pot – instead, use a spoon or pump dispenser as this reduces the risk of spreading infection

It is very important to keep using your emollients during a flare-up because this is when the skin needs the most moisture. During a flare-up, apply generous amounts frequently.

Topical corticosteroids

Topical corticosteroids are usually prescribed when the skin is inflamed. Topical means something applied directly to your skin. Corticosteroids work by quickly reducing inflammation.

You may be concerned about using medication that contains steroids. However, corticosteroids are not the same as anabolic steroids, sometimes used illegally by bodybuilders and athletes. When used correctly, corticosteroids are a safe and effective treatment for eczema.

Choosing a topical corticosteroid

Topical corticosteroids can be prescribed in different strengths, depending on the severity of your atopic eczema. They can be mild, such as hydrocortisone, moderate, such as clobetasone butyrate, strong or very strong. Severe cases of atopic eczema will require stronger corticosteroids. You may be prescribed: 

  • a cream to be used on visible areas, such as the face and hands
  • an ointment to be used at night or for more severe flare-ups

If you need to use corticosteroids frequently, see your GP regularly so they can check the treatment is working effectively and that you are using the right amount.

How to use topical corticosteroids

Apply the treatment sparingly to affected areas. Always follow the directions on the patient information leaflet that comes with the corticosteroid.  

During an atopic eczema flare-up, do not apply the corticosteroid more than twice a day. Most people only have to apply it once a day. To apply the topical corticosteroid:

  • apply your emollient first and wait 30 minutes until the emollient has soaked into your skin
  • apply the recommended amount of the topical corticosteroid to the affected area 
  • apply the treatment for 48 hours after the flare-up has cleared so the eczema under the skin is treated

If you or your child are using corticosteroids for a long time, they may need to be applied less frequently. Speak to your GP for advice.

How much topical corticosteroid to use

Topical corticosteroids are measured in a standard unit called the fingertip unit (FTU).

  • one FTU is the amount of topical corticosteroid squeezed along an adult's fingertip
  • one FTU is enough to treat an area of skin twice the size of an adult's hand

Read more information about fingertip units and dosage of topical corticosteroids.

Side effects

Topical corticosteroids may cause a mild burning or stinging feeling as you apply them.

If strong topical corticosteroids are used for too long, they may also cause:

  • thinning of the skin, particularly in the crease of the elbow or knee joint
  • visible blood vessels, particularly on the cheeks
  • acne
  • increased hair growth

These side effects are rare.

Antihistamines 

Antihistamines are a type of medicine that stops the effects of a substance in the blood called histamine. Your body often releases histamine when it comes into contact with an allergen.

Antihistamines can help you cope with the itching that atopic eczema causes. They can be sedating, which cause drowsiness, or non-sedating.

Non-sedating antihistamines

You may be prescribed a non-sedating antihistamine if you have severe itching or associated hay fever. If this helps, you may be advised to continue taking the non-sedating antihistamine in the long term. This should be reviewed every three months.

Sedating antihistamines

If itching affects your sleep, a sedating antihistamine may help. Sedating antihistamines are prescribed on a short-term basis, usually for a maximum of two weeks at a time, as they seem to lose their effect quickly.

These types of antihistimine can cause drowsiness the following day, so it's a good idea to let your child's school know that they may not be as alert as normal.

If you are taking sedating antihistamines, avoid driving the next day if you still feel drowsy. The sedative effect is likely to be stronger if you drink alcohol.

Corticosteroid tablets

In rare cases, if you have a severe flare-up your GP may prescribe corticosteroid tablets. These are also used for flare-ups of asthma.

You may be prescribed prednisolone to take once a day, usually in the morning, for one to two weeks.

If oral corticosteroids are taken often or for a long time, they can cause side effects such as:

For this reason, your GP is unlikely to prescribe corticosteroid tablets more than once a year without referring you to a specialist.

Infected eczema

Antibiotics are usually prescribed if eczema becomes infected.

Large areas of infected skin are usually treated with antibiotic tablets or capsules. The antibiotic most commonly prescribed is flucloxacillin, which is usually taken four times a day for seven days. If you are allergic to penicillin, you may be prescribed:

Small areas of infected eczema are usually treated with antibiotic creams or ointments applied directly to the infected area.

Topical antibiotics should not be used for longer than two weeks because the bacteria may become resistant to the medication. If your symptoms get worse, speak to your GP.

Preventing infections

Once your infection has cleared, your GP will prescribe new supplies of any creams and ointments you're using to avoid contamination. Old treatments should be disposed of.

During and after infection it's important to keep inflammation under control with corticosteroids.

If areas of your eczema are prone to infection, antiseptic cream or lotion can help kill any bacteria. Commonly prescribed topical antiseptics include chlorhexidine and triclosan. 

Referral 

In some cases of atopic eczema, your GP may refer you to a specialist in treating skin conditions (dermatologist). You may be referred if:

  • your GP is not sure what type of eczema you have
  • treatment is not controlling your eczema  
  • the eczema is causing significant problems in your daily life
  • it is not clear what is causing your eczema 

A dermatologist may offer the following treatments:  

  • phototherapy – exposure to ultraviolet (UV) light
  • bandaging – medicated dressings or wet wraps are applied to your skin
  • an immunosuppressant medication – to suppress your immune system
  • very strong topical corticosteroids
  • additional support on using your treatments correctly – such as demonstrations from nurse specialists 
  • psychological support
  • alitretinoin 

Alitretinoin

Alitretinoin, sold under the brand name Toctino, is a medication for severe, long-term hand eczema that has not responded to other treatments. Treatment with alitretinoin must be supervised by a dermatologist and can only be used by people 18 years of age or over.

Alitretinoin is a type of medication called a retinoid. Retinoids reduce levels of irritation and itchiness associated with eczema. It comes as a capsule that most people are recommended to take once a day for 12-24 weeks.

Alitretinoin should never be taken during pregnancy because it can cause severe birth defects. Women who are breastfeeding should also avoid taking alitretinoin, because the medication can enter your breast milk and harm your baby.

Due to the risk of birth defects, alitretinoin is not recommended for women of child-bearing age.

Some common side effects of alitretinoin include:

  • headaches
  • dry mouth and eyes 
  • a reduced number of red blood cells, known as anaemia
  • increased levels of fatty substances called cholesterol and triglyceride in the blood 
  • joint pain or muscle pain

For a full list of side effects, see the patient information leaflet that comes with your medicine or alitretinoin medicines information.

 

Page last reviewed: 21/11/2012

Next review due: 21/11/2014

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Comments

The 3 comments posted are personal views. Any information they give has not been checked and may not be accurate.

heleng327 said on 03 January 2014

I too use a brush to scratch eczema. I have done since I was 13 when I get flare ups (I am now 27). It doesn't break the skin but provides great relief. I get my eczema on my hands now and I don't know what flares it up. I wake up in the night scratching my hands. I have tried wearing gloves to no avail. I would love to have some relief from this.

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Leonard Spellman said on 02 April 2013

I have eczema. Confined to legs, especially in areas of hips, knees and ankles. Duration ten years. I am 77 years of age. As an experiment some six weeks ago I brushed each area of inflamation with a fairly stiff brisled hair brush. I experienced an almost immediate sense of relief of both irritation and inflamation and, for the first time in many years, enjoyed a full night's sleep. I have continued to brush my skin in the affected areas as a routine and, of course, whenever experiencing irritation. During this period I have not had cause to use any medication, e.g. Bentnovate cream. I would estimate that my eczema is currently about 90% reduced. Indeed, at times I enjoy a whole day without being reminded I have the condition. Therefore, I feel confident to pass this on to others. There is nothing to lose so far as I can see. I would be very intersted to hear from anybody who tries this technique.

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ckbridgett said on 02 August 2012

Thank you for this useful review. I would add when atopic eczema becomes chronic or longstanding, lasting longer than two weeks regardless of emollient and topical steroid, consider review of treatment to ensure it is optimal, and add habit reversal to deal with habitual scratching. This "combined approach" needs then to be maintained for four weeks, and then the remission maintained by using emollients and topical steroids assertively for only a few days at a time fore acute flare-ups.
Dr CK Bridgett Chelsea & Westminster Hospital London

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