- Regular use of emollients is likely to reduce the risk of eczema flares and the need for topical corticosteroids.
Treatment adherence can be improved by prescribing simple regimens and ensuring patients and caregivers know how to
- For children with widespread eczema, prescribe at least 250 g of their preferred emollient per week for use as
a leave-on product. Older children, e.g. those aged over ten years, with widespread eczema may
need up to 500 g of emollient per week.
- The subsidised formulation of aqueous cream no longer contains sodium lauryl sulphate (SLS – a known skin irritant)
and can be used both as a leave-on emollient and a soap substitute. Emulsifying ointment
contains SLS and should not be used as a leave-on emollient, it is however, an effective soap
- Advise patients to keep fingernails trimmed, avoid irritants, e.g. soaps, and to wear cotton rather than woollen
clothing next to their skin
- Use the lowest potency topical corticosteroid needed to control the patients symptoms; avoid the term “use sparingly”
and encourage appropriate use
- For children with frequent flares, e.g. two flares per month, “weekend treatment” with topical corticosteroids
may reduce the frequency of flares and overall corticosteroid use
For information on the use of topical corticosteroids in childhood eczema, see the companion article:
“Topical corticosteroids for childhood eczema: clearing up the confusion”.
Eczema is characterised by dry skin (xerosis), reduced skin barrier function, cutaneous inflammation with increased
susceptibility to irritants, and higher rates of Staphylococcus aureus colonisation and skin and soft tissue
infection.1, 2 Recurrent flares of eczema can adversely affect a child’s sleep, focus at school and social
interactions. Eczema typically improves as children move into their teens, although research suggests half continue
to experience some symptoms at age 20 years.3
Emollients and topical corticosteroids are effective at preventing and treating flares of eczema, and can reduce S.
aureus skin colonisation, poor adherence, however, often reduces their effectiveness.2, 4, 5
The prevalence of eczema is higher in Māori and Pacific children (approximately 20%), compared to children of European
ethnicity (14%), therefore these families may benefit from additional support.6
Emollients (moisturisers) are topical formulations which reduce transepithelial water loss and hydrate the skin to
improve barrier function. These form the basis of treatment for patients with all degrees of eczema severity.1,
2 They are also used alongside topical corticosteroids to treat active inflammation.
Appropriate use of emollients:1, 7
- Reduces the amount of topical corticosteroids required
- Improves symptoms
- Reduces flares or relapses
- Improves sleep and quality of life
Types of emollient
A range of subsidised emollients are available (Table 1).
Lotions have a higher water content than creams or ointment, and can evaporate quicker requiring
more frequent application.8 They are not generally recommended for use in children with eczema.
Creams are more effective than lotions and are usually more cosmetically acceptable than ointments
as they are absorbed faster into the skin.2 Additives such as glycerol and urea attract and hold water.
Creams are preferred to ointment if skin is weeping or oozing (see below).9
Ointments form an occlusive layer which prevents evaporation of water from the outer layers of the
skin. Ointments are greasier and thicker and may be less cosmetically acceptable, but are more effective
at preventing evaporation. They are more difficult to wash off, with the exception of emulsifying ointment which can
be used as a soap substitute. Ointments may be more suitable than creams for patients with more severe symptoms, e.g.
dry, scaly areas of skin, but may cause a build up of exudate if used on skin that is weeping or oozing.
Emollients or soap substitutes which contain fragrances may cause irritant
dermatitis. In addition, care should be taken when using topical applications which contain
sodium lauryl sulphate (SLS) as this is a skin irritant and can worsen eczema symptoms. Products
containing SLS should not be used as leave-on emollients but can be used as soap substitutes, e.g.
emulsifying ointment.10 The
subsidised aqueous cream BP is SLS-free and can therefore be used as a leave-on emollient. Some unsubsidised
brands of aqueous cream and over-the-counter emollients contain SLS and should not be used as leave-on
emollients for children with eczema.
Selecting an appropriate emollient
Large quantities of emollients are required to manage eczema effectively and therefore fully-subsidised products
are likely to be preferred by many families. Patients may need to trial different products to find
an emollient which is acceptable and effective. There is no clear evidence as to which emollient
is most effective, so patients should be prescribed their preferred option to improve treatment adherence.1 If
a particular emollient irritates the skin, patients should trial a different product. Caregivers
of very young children should watch for signs of discomfort or increased skin irritation when using
a new emollient.
There are few studies evaluating whether plant oils are beneficial for patients with eczema, but some positive results
have been reported for specific products, such as coconut oil.11, 12
Patients may need different emollients for different body areas and symptomatic areas of skin may require treatment
with different emollients during flares. For example, creams can assist with inflammation, as the evaporation of water
cools the skin, whereas greasy ointments are more suitable for dry skin.1, 2
To reduce unnecessary wastage, consider giving caregivers a trial prescription for a limited period, e.g. one week.
For further information on how to write trial prescriptions, see: www.bpac.org.nz/BPJ/2015/August/pills.aspx
Talk to your local pharmacist about having a selection of emollients available in the practice to demonstrate
their consistency and application to patients.
Most patients do not use enough emollients
Apply emollients during both symptomatic and asymptomatic periods. The appropriate amount of emollient varies according
to the patient’s body size and the area of skin affected (Table 2). Most patients use too little
- For widespread eczema prescribe at least 250 g per week, for application at least two to three times per day. Older children, e.g.
those aged over ten years with widespread eczema, may need up to 500 g of emollient per week.1
- An additional quantity or emollient should also be prescribed as a soap substitute for use when bathing
- Apply emollients in the direction of hair growth 1
Emollients ideally should be removed from tubs with a clean spoon or spatula to minimise the risk of bacterial contamination.2 Pump
bottle dispensing of emollients also reduces risk. Advise caregivers to check the expiry date of the emollient, as
contamination risk is increased when products are used beyond this date.
Prescribe emollients as a soap substitute
Patients with eczema should avoid soaps and use emollients such as emulsifying ointment and aqueous cream as soap
substitutes when bathing. To provide patients with a simple treatment regimen, prescribe an emollient suitable for use
as a soap substitute and a leave-on moisturiser. The use of bath oil (unsubsidised) once to twice daily during periods of
active eczema is thought to be beneficial.13 Care needs to be taken when bathing with soap substitutes
and oils as these can make surfaces slippery. There is no clear evidence as to whether showering
or having a bath is better for controlling symptoms. The optimal frequency of bathing is also unknown.8 When
drying the skin after bathing, it should be patted rather than rubbed.
Emulsifying ointment cleans and moisturises the skin and can be made into an effective soap substitute
with easy-to-use consistency by mixing three to four large spoonfuls with very hot water to achieve a creamy soap consistency.
Once cool, this can be used in the shower or bath and more prepared as required. Instructions for preparation can be included on the prescription label.
Many patients find bleach baths beneficial, however, recent studies suggest that evidence is mixed as to whether bleach
baths improve symptoms.18–21 Caregivers should avoid using fragranced bleach.
Information on how to prepare a bleach bath is available from: www.bpac.org.nz/BPJ/2015/April/eczema.aspx
Table 2: Approximate quantities of emollient for children with eczema depending on patient
age and area of body affected.17
||Quantity of emollient per week*
||3 months to 2 years
||3 – 5 years
||6 – 10 years
||10 – 18 years
|Area of the body:
|Both arms or legs
||30 – 50 g
||50 – 100 g
||100 – 200g
||50 – 100g
* The amounts shown above are usually suitable for twice daily application for one week. If emollients
are used more frequently, larger amounts will be required. Additional amounts will be required for use as a soap substitute.
Topical corticosteroids should be applied on all areas of active eczema, no matter how severely inflamed, and stopped
once the eczema has cleared (unless following “weekend treatment”, see below). Once daily application may be sufficient,
especially if treatment is initiated when symptoms first develop.2 The
potency of the topical corticosteroid should be appropriate
for the area of the body being treated, the age of the patient and their symptom severity, e.g. mildly inflamed eczema on
the hands will typically need a potent steroid for treatment to be effective.
For further information on assessing the severity of eczema symptoms, see:
Encourage caregivers to continue emollient use during flares. Either emollients or topical corticosteroids can be
applied first with only a short interval needed between applications.1 The practice of waiting up to 45
minutes between applications is not evidence-based and can reduce adherence.22
Topical pimecrolimus (unsubsidised), a calcineurin inhibitor, is a second-line treatment option for patients with
eczema if the use of topical corticosteroids is contraindicated or inappropriate, e.g. for long-term
use on body areas such as the face, neck and groin.1 Pimecrolimus may be as
effective as mild to moderate potency topical corticosteroids for the treatment of eczema, but is more likely
to cause a burning sensation and pruritus.23 Concerns regarding a possible association
between topical calcineurin inhibitor use and increased risk of lymphoma have been raised based on
studies in animals, however, studies in humans have not established an increased risk of malignancy.24, 25
For further information on the use of topical pimecrolimus, see:
Maintenance treatment with topical corticosteroids can reduce the frequency of flares
Eczema is traditionally managed reactively, where topical corticosteroids are initiated during a flare and stopped
when symptoms resolve. This approach is still appropriate for many patients.
Children with frequent flares, e.g. two per month, may benefit from a proactive approach, where topical corticosteroids
are applied twice a week during periods of remission, i.e. between flares.1 This is often referred to as “weekend treatment”, however,
treatment can occur on any two consecutive days in the week.1
For further information on weekend treatment, see: “Topical
corticosteroids for childhood eczema: clearing up the confusion”.
Use oral rather than topical antibiotics for infected eczema
Antibiotic treatment of infected eczema is not always necessary. If antibiotic treatment is needed, oral antibiotics are preferred over
topical antibiotics due to increasing rates of fusidic acid resistance in New Zealand. Recently released data show that 21–46% of community acquired S.
aureus infections were fusidic acid resistant in 2014.26
Studies suggest a watch and wait approach may be appropriate for patients with mild to moderately infected eczema;
oral antibiotics can be reserved for patients with worsening or severe infection.27 A double-blind randomised
controlled trial in primary care in the United Kingdom found that for children with mild to moderately infected eczema,
the use of topical or oral antibiotics had no effect on symptom severity or made eczema symptoms worse. Children with
severe infection were excluded from this study.
If antibiotic treatment is required, a suitable first-line oral regimen is:28
- Flucloxacillin 12.5 mg/kg/dose, four times daily, for five days (maximum 500 mg/dose)
Flucloxacillin capsules can be prescribed for older children who are able to swallow them. Alternative oral antibiotic
choices include erythromycin, co-trimoxazole or cephalexin.
Dosing regimens are available in the bpacnz antibiotic guide:
For patients with recurrent infected eczema, the focus should be on managing the eczema effectively. Appropriate
use of topical corticosteroids and emollients can improve the skin microbiota of people with eczema and reduce S.
aureus skin colonisation.4, 5, 20, 29, 30
There is little evidence to suggest topical corticosteroids worsen the course of bacterial or viral skin infection,
and they may improve skin barrier function.31 Topical corticosteroids can continue to be used on excoriated
skin and eczema with bacterial or viral infection. However, topical corticosteroids should be stopped in patients with
fungal infections as they may exacerbate the infection.2, 31
Antihistamines may benefit children with severe symptoms
Antihistamines are not routinely used children with eczema, but a bedtime dose of a sedating antihistamine can be
trialled to aid sleep in children aged over two years during
an eczema flare:2, 13 see NZFC, www.nzfc.org.nz, for dosing recommendations.