Acute eczema presents with intense redness, vesicles and blisters. The eruption may be localized or widespread. Intense itching is often present. Cold wet compresses provide immediate relief of symptoms. Soak cloth in cold water. Apply the very wet cloth to the involved areas for 20-30 minutes. Repeat this treatment several times a day until the intensity of the inflammation subsides and the blisters are broken. Wet compresses cool the skin and reduce the intensity and duration of inflammation.
Prednisone is indicated for patients with widespread inflammation who are very uncomfortable. Wet compresses are still used even if the patient requires prednisone. A typical dose of prednisone for the average size adult is prednisone 20 mg twice a day for 7-10 days followed by 20 mg a day in the morning for 3 days. That program should be adequate to treat most cases of poison ivy. Patients treated with steroid dose packs in which the dosage of prednisone or a similar oral steroid is rapidly decreased over several days will probably respond. However others may not improve or even get worse with this low dose rapid taper program.
Acute eczema will evolve into subacute eczema with just redness and scaling. Diseases such as atopic dermatitis or stasis dermatitis may present initially as just subacute eczema. All of these patients are treated with topical steroids. The most commonly used preparation is triamcinolone acetonide cream 0.1. This comes in a 15 g or 80 g tube. The cream is inexpensive. Numerous companies make this generic drug and unfortunately the potency may vary from company to company. This group 5 topical steroid may or may not be of adequate strength to control the inflammation.
Desoximetasone cream 0.25 is a group 2 topical steroid and is more predictably effective than triamcinolone. The medication can be expensive. The price varies widely from pharmacy to pharmacy. Fluticasone cream is an excellent preparation for treating young children. It is safe and effective.
These medications are applied once or twice a day for 7-21 days until the inflammation is controlled. Excessive washing is discouraged. Bland emollients may be used during the treatment period and after recovery.
Highly potent topical steroids such as clobetasol are usually not required.
Tar creams and ointments were used prior to 1950 when topical steroids were not available. This medication may be effective and can be used in patients who are reluctant to use topical steroids. These are all available over-the-counter.
Nonsteroidal anti-inflammatory agents such as Protopic and Elidel can be used as steroid sparing medications. Treat first with a topical steroid to control inflammation. Patients who are unstable and flair repeatedly can be intermittently treated with nonsteroidal anti-inflammatory agents to avoid long-term continuous use of topical steroids.
Chronic eczema usually presents with thickened red scaly skin. The area has usually been scratched for days and weeks. Cold compresses are avoided because they would further dry the skin. Topical steroids are used in a similar fashion to that described for the treatment of subacute eczema. Difficult cases in which skin is thickened and rough may respond to the most potent steroid clobetasol. This must be used for a short specified time such as 2-4 weeks. Continuous use of potent topical steroids causes skin thickening and atrophy.
Occlusive therapy is highly effective. Apply the topical steroids mentioned above under subacute eczema and cover with a plastic wrap such as Saran wrap. The plastic dressing does not have to be airtight. Secure the dressing with tape on either end. A sock will hold the plastic dressing against a foot. The dressing may stay on for 2 hours or overnight. Remove the dressing and apply an emollient or more medication. It is not necessary to wash the skin each time a plastic dressing is applied. The appearance of pustules indicates a secondary infection. Stop treatment and prescribe topical or oral antibiotics for this side effect of occlusive therapy.
Eczema of any stage or any type may become infected. Intense redness, blistering, serum or crusting are signs of a possible infection. Patients who present with eczema and signs of infection will rapidly improve with just topical or oral antibiotics as initial treatment. Once infection is controlled then topical steroids can be introduced.