Evidence-Based Management of Eczema

Five Things That Should Be Done More and Five Things That Should Be Dropped

Bayanne Olabi; Hywel C. Williams


Curr Opin Allergy Clin Immunol. 2021;21(4):386-393. 

In This Article

Abstract and Introduction


Purpose of Review: We provide readers with an evidence-informed opinion on current treatments for eczema (atopic dermatitis) with the intention of improving patient care. We suggest five treatment aspects that should be promoted and five that should be demoted. Evidence sources include key randomized controlled trials and systematic reviews.

Recent Findings: Under-treatment of eczema can be countered by more aggressive use of topical therapies including the 'get control then keep control' regimen, and systemics for severe disease, supplemented with good patient education. Topical corticosteroids should be used once daily rather than twice daily. Topical calcineurin inhibitors are useful for sensitive sites. There is little evidence to support the continued use of oral antihistamines, oral or topical antistaphylococcal treatments for infected eczema or probiotics for treating eczema. Nonpharmacological treatments including silk clothing, ion-exchange water softeners and emollient bath additives have not been shown to benefit eczema patients. Despite promising pilot studies, large trials suggest that emollients from birth do not prevent eczema and may result in harms such as increased skin infections and food allergy.

Summary: New evidence-based insights on existing and newer treatments allow clinicians the opportunity to change their practice in a way that enhances patients' quality of life.


Eczema (syn atopic eczema or atopic dermatitis) management is a partnership with a patient that involves an explanation of the disease, management of acute flares and long-term control by adopting a holistic, patient-centred approach. Good communication is of paramount importance in order to ascertain how patients (and their families) cope with eczema and to provide education in order to negotiate evidence-based management approaches.

Over the last 12 years, the Centre of Evidence-Based Dermatology (CEBD) has conducted annual updates of systematic reviews related to various aspects of eczema management[1–3] with a focus on critical appraisal, in order to inform clinical practice. Topics include epidemiology,[4] disease mechanisms,[5] risk factors,[6,7] prevention,[8] topical[3] and systemic therapies.[2] We use this comprehensive resource of appraised systematic reviews as the main evidence source for this article, supplemented by key randomized controlled trials (RCTs).

Many longstanding practices in the clinical setting are ingrained, often with uncertain origins. Why are most topical corticosteroid (TCS) preparations advised to be applied twice daily? Why are topical antibiotics used in combination with TCS? Why are antihistamines used frequently if the itch of eczema is not caused by histamine? Although it is difficult to change longstanding well intentioned prescribing habits, as exemplified by the international 'Choosing wisely' campaign, it is important for clinicians and their patients to choose care that is supported by evidence and which is truly necessary.[9] By providing a focus on recent evidence-based findings in studies of eczema management that reflect the whole spectrum of disease severity, we herein present five interventions we wish to promote, and five interventions we wish to demote.