First-line treatment

Introduction
The treatment of eczema should reflect the needs of the individual
and their eczema. The extent of the eczema and the areas affected
will influence the choice of treatment. Although there are a variety
of different treatment approaches, first-line therapy usually involves
a topical skin-care regime in which creams or ointments are applied
directly to the skin. This usually involves the regular use of
moisturisers with the addition of topical steroids as an active
treatment when needed.
Skin-care regimes such as these are the mainstay of eczema
management, but they can be messy, fiddly and time-consuming,
leading to a potential underuse or misuse of treatment and
difficulties of ‘sticking’ to the regime. With a chronic condition such
as eczema, the results of treatment are not always instant or clearly
visible, hence it can be difficult to maintain motivation and
concordance with therapy. It is the skill of the doctor or nurse to
enthuse, inform and educate those with eczema so that they can
make informed treatment decisions in partnership with health-care
professionals. This is why we use the term ‘concordance’ instead
of the more old-fashioned term ‘compliance’ as it reflects some
agreement on the type of treatment regime chosen. In addition, it
is important to be aware of other sources of information, such as
the National Eczema Society.
Overall, the key thing to consider with the management of
eczema is to be realistic about treatment expectations. Eczema is
a chronic condition, and therefore the aim of treatment is improved
management and maintenance. Clearance may be attained in the
short term, but a cure is not possible. When deciding on the mode
of treatment, one must consider the fine balance between clearance
and the potential of side-effects of the treatment. To better illustrate
this point, think of a couple of different scenarios: for a child a
realistic expectation might be to control the eczema at a level that
does not interfere with social, psychological or physical
development, whereas with adults the goal may be to maintain
eczema at a level that does not interfere with a desirable quality
of life. This can be much more realistic and achievable than always
aiming for completely clear skin.
No matter how well eczema is controlled, there will always be
the occasion when a flare is experienced. The nature of eczema is
to fluctuate: a flare is not an indication that treatment has failed
but just an indication to step up a gear to tackle a more severe
presentation. It is therefore helpful to think of first-line eczema
treatment as having two phases. The first is a maintenance phase
consisting of a weaker treatment regime that will continue as long
as the eczema has the potential to cause problems; the second is
a stronger set of creams to use in the short term when the condition
flares. A recent study of attitudes to eczema treatment interviewed
200 patients across Europe, with the following findings:
• 75% of patients/carers said that being able to control the
eczema effectively would be the single most important
improvement to their quality of life;
• 55% admitted to worrying about the next flare (36%
sometimes worried, 19% always worried);
• patients with moderate eczema spent an average of 97 days
each year in a flare, whereas for those with severe eczema
the figure was 146 days;
• 66% of patients/carers used topical steroids only as a last
resort; 58% restricted their use of topical steroids to certain
body areas owing to concern about side-effects, and 39%
used them less frequently than their doctor recommended,
for the same reason;
• 67% of patients/carers said that their preferred treatment
option was to apply a non-steroid treatment as early as
possible to prevent a flare.