To manage infection in eczema, the BNF proposes short, one week courses of topical or oral antibacterials where S. aureus (occasionally Streptococcus pyogenes) is exacerbating eczema. Topical steroids can be used alongside to manage the eczema if necessary.30

Topical preparations for seborrheic dermatitis use ketoconazole or other antifungals to target the Malassezia yeast.

Alternatives include combination antiseptic and emollients, or anti-fungal lotions/shampoos (eg ketoconazole, coal tar). Infected eczema in skin folds may need treating for candida infection. For eczema herpeticum, oral antivirals may be required.30

Note that bandages and garments should never be used on infected skin.32

Thickening or lichenification of the skin from scratching may require a topical potent corticosteroid. Coal tar or ichthammol may also be effective in chronic eczema.30

Phototherapy (with UVA light) or immunomodulating drugs (eg ciclosporin or dupilumab) may be needed in severe refractory eczema. Use of azathioprine or mycophenolate mofetil is off-label.5,30,31

Alitretinoin is licensed for use in adults with severe chronic hand eczema that is unresponsive to treatment with potent topical corticosteroids. It can also be used in patients where hyperkeratinisation is a feature, rather than pompholyx-type eczema.30