Managing an eczema flare

In brief

• Most people with eczema have flares of red, intensely itchy, inflamed skin, and a flare doesn’t mean you’ve done something wrong.
• Start treatment early, and moisturise more often during a flare, not less.
• Topical corticosteroids are the first-line treatment, with the strength chosen for the body area and the amount measured in fingertip units.
• Calcineurin inhibitors suit the face, eyelids and skin folds; wet wraps can help severe flares, ideally first with clinic guidance.
• Come back if a flare isn’t improving after about 2 weeks of treatment.
• Come in the same day for weeping skin, honey-coloured crusts, pus, fever, or many small blisters or punched-out sores appearing suddenly.

We treat eczema flares at our Punggol clinic. Book a skin appointment.

Spotting a flare early

Even with good daily skincare, most people with eczema have flares: periods of red, intensely itchy, inflamed skin. A flare is not a sign you’ve done something wrong; it is how the condition behaves.

Catching a flare early usually means treating a smaller patch with less treatment. Early signs include:

• Skin feeling itchier than usual
• Small patches of redness (or darker, violet or grey patches in Asian skin) returning to your usual “trouble spots”
• Dryness worsening despite your normal moisturising
• Sleep disturbed by night-time itching

If you notice these, don’t wait. Starting treatment early, sometimes the same day, usually controls a flare faster than waiting until the skin is cracked, weepy or infected.

Your moisturiser when you’re flaring

During a flare, daily moisturising becomes more important, not less. Your everyday routine continues alongside flare treatment, with a few changes:

• Switch to something plainer if your moisturiser stings. Urea, fragrance, strong humectants or active ingredients can sting inflamed skin. A ceramide cream without actives, or a plain oil-based ointment such as petrolatum (Vaseline), is usually better tolerated.
• Pause urea-containing moisturisers until the skin is calm.
• Apply more often: several times a day, not just twice.
• For itch, a moisturiser with 1–3% menthol (over the counter) gives short cooling relief by acting on the skin’s cold receptors. Use it as well as, not instead of, your usual emollient. A few people react to menthol; if it worsens the skin, stop.

Not sure your moisturiser is helping? Bring it to your consultation and we’ll suggest alternatives.

Topical corticosteroids — the first-line treatment

Topical corticosteroids (TCS) remain the first-line anti-inflammatory treatment for flares, and they work very well for most mild and moderate flares.

Your doctor chooses the strength for the body area and the severity of the flare:

• Thin-skinned areas (face, neck, eyelids, groin, and the folds of the arms and knees) need gentler, low-potency steroids for short periods.
• Body skin (arms, legs, trunk) can take moderate- or higher-potency steroids during flares.
• Very severe flares may need higher-potency steroids for a limited period.

Your doctor sets the dose and frequency. Ask before using a tube from an old prescription on a new patch of skin.

How much to apply — the fingertip unit

A fingertip unit (FTU) is the standard measure for topical steroids:

• One FTU is the amount squeezed from a standard tube along an adult index finger, from the tip to the first crease.
• One FTU covers about two adult palms of skin (including fingers).

Your doctor will tell you how many FTUs to use on each area. Too little is a common reason a flare doesn’t settle; too much, or too strong, carries the risks discussed below.

When to stop — and “proactive therapy” for frequent flares

For occasional flares, apply daily until the area is clear, then stop. Moisturiser continues throughout.

If you have frequent flares (two or three a month) on the same patches, ask about proactive therapy. Once a flare is controlled, you apply a topical steroid (or a calcineurin inhibitor) to those spots twice a week. This stops low-level inflammation building into a full flare. Over time, it reduces the total amount of steroid you use compared with treating each flare as it comes.

We plan proactive therapy with you after a few flares, review it every 3 to 6 months, and stop once you’ve been flare-free for a while.

Topical calcineurin inhibitors — the steroid-sparing option

Topical calcineurin inhibitors (TCIs), pimecrolimus (Elidel) and tacrolimus (Protopic), are non-steroid anti-inflammatory creams. They suit:

• The face, eyelids, neck and skin folds, where long-term or repeated steroid use is a concern
• People who prefer a non-steroid option
• Proactive therapy, instead of or alongside a topical steroid

They can burn or sting for the first few days, which usually settles. The old FDA “black-box” warning about a theoretical cancer risk has not been borne out by long-term human studies, and dermatologists worldwide now use them routinely. Approved age limits in Singapore: pimecrolimus from 3 months of age; tacrolimus 0.03% from age 2; tacrolimus 0.1% from age 16.

If your flare is on your face, around your eyes, or keeps returning to the same sensitive spot, ask us about TCIs. They are underused in primary care and very useful.

Wet wrap therapy

Wet wrap therapy (WWT) is a short-term step up for severe flares, typically on the limbs, with intense night-time itch and scratching that isn’t responding to usual treatment. Wraps hold hydration against the skin, boosting the effect of moisturiser and any steroid underneath. The dry outer layer also protects against scratching overnight.

How to do it

The basic technique uses three layers:

1. Prepare the skin. Take a short lukewarm bath or shower and pat dry, leaving the skin slightly damp, not wet.
2. Apply flare treatment first. Put on the prescribed steroid, if any, wait a few minutes, then add a generous layer of moisturiser. Without a steroid, use a thick layer of moisturiser only.
3. Inner layer: damp cotton. Soak a soft cotton garment (long-sleeved top, pyjamas, tubular bandage or cut-up gauze) in warm water and wring it out well, so it is damp, not dripping. Put it on over the treated area.
4. Outer layer: dry cotton. Put dry cotton clothing on top to hold it in place and prevent chilling.
5. Leave on for 1–2 hours, up to overnight. Start with a few hours and build up to overnight as the skin tolerates it.
6. Remove, re-moisturise and put on dry clothes. Wraps usually continue nightly for 3–5 days, then we reassess. They are a short-term tool, not a routine.

When not to use wet wraps

Come in before starting if:

• The skin is weeping, oozing or infected. Wraps can trap bacteria and worsen infection.
• There are honey-coloured crusts, pus or fever, or other signs of eczema herpeticum or bacterial infection.
• The patient is a very young infant. We recommend clinic supervision for the first wraps in under-2s, and never on large areas in infants.
• The skin is being treated with a calcineurin inhibitor (pimecrolimus, tacrolimus) or topical PDE4 inhibitor, unless we have advised it, as the safety of covering these hasn’t been fully established.
• The person can’t tolerate the wrap (too cold or uncomfortable). Don’t persevere; try another day.

Things to watch for

• Chilling, especially in children. Keep the room warm and the outer layer warm.
• Skin softening or pruning is normal if mild. If the skin breaks down or develops small spots (folliculitis), stop and come in.
• Worsening itch or burning during the wrap: remove it and reassess.

Do your first wrap with clinic guidance, especially for children. Details such as how damp is damp, which garments to use, and whether a steroid under the wrap suits you make the difference.

Itch and sleep

Itch that disrupts sleep is one of the hardest parts of a flare. The first step is always to treat the inflammation; the itch follows. Cool compresses, cool (not cold) showers, and pressing or rubbing instead of scratching help bridge the first day or two.

Oral antihistamines don’t treat eczema itch well, because most eczema itch doesn’t come from histamine. That is why hay fever or hives tablets disappoint here. However, a short course of a sedating (first-generation) antihistamine at bedtime, such as hydroxyzine or chlorpheniramine, can break the scratch-and-wake cycle in a severe flare, mainly by helping you sleep. It is not for routine daily use: longer use brings drowsiness, dry mouth and skin, and a risk of falls, especially in older people. Your doctor will prescribe a short, time-limited course if appropriate.

Concerns about steroids

Many people are uneasy about topical steroids. We would rather discuss this than have you under-treat a flare and get worse.

• Topical steroids are not oral steroids. Far less is absorbed into the body, and the side effects are very different.
• The risks (skin thinning, visible blood vessels, stretch marks) come mainly from high-potency steroids used long-term on thin-skinned areas, not from well-chosen flare treatment.
• Under-treating a flare has its own risks: more scratching, more skin damage and more infection.
• Proactive therapy reduces your total steroid exposure over time compared with repeated courses.

If you’ve been told online or by friends to avoid steroids entirely, raise it with us rather than leave with a prescription you won’t fill.

A note on “triple-combination” creams

Some patients bring creams with three ingredients in one: usually a steroid, an antibiotic and an antifungal. They have a place in specific situations but are not our preferred choice for routine eczema. The steroid is often stronger than needed, and most flares don’t need the antibiotic or antifungal.

If one works for you, continue as directed. If your eczema isn’t settling on it, come in. It usually needs a review, and sometimes tests, rather than more of the same.

Topical steroid withdrawal

Topical steroid withdrawal (TSW), or “red skin syndrome”, is a recognised condition after prolonged use of medium- or high-potency topical steroids followed by abrupt stopping, most often on the face or in skin folds. It typically causes burning or stinging and widespread redness, sometimes beyond where the steroid was applied. It can be mistaken for a bad eczema flare.

• TSW is real but uncommon when steroids are used appropriately: right potency for the site, right duration, and weaned off rather than stopped abruptly after long-term use.
• Most rebound after stopping a steroid is the eczema flaring, not TSW. The two can be hard to tell apart, so work it through with your doctor rather than stopping on your own.
• Proactive therapy lowers total steroid exposure over time, one of the best ways to avoid TSW.
• Don’t stop long-term topical steroids abruptly. If you’ve used a moderate-to-strong steroid daily for a long time and want to stop, come in. We’ll plan a gradual step-down, such as a weaker agent, less frequent use, or bridging with a calcineurin inhibitor.

If you have burning or redness spreading beyond your usual eczema pattern, come in for assessment. We would rather support you through it than have you self-treat alone.

Oral steroids — the short answer

Oral corticosteroids are not used routinely for eczema, even in flares. They work quickly, but eczema tends to rebound worse afterwards, and repeated use carries real long-term risks. When used, they are a short, tapered course under supervision: for a severe flare not settling with topicals, or as a short “bridge” while a slower treatment takes effect.

In children, we are especially careful because of the effect on growth.

If a flare isn’t responding to topical treatment

This usually means it’s time to come in rather than keep applying the same treatment. We look for why it isn’t working. Common reasons:

• Secondary bacterial infection. Honey-coloured crust, oozing or rapid worsening often means infection, which needs antibiotics alongside the anti-inflammatory treatment.
• The wrong potency, frequency or duration of steroid for the site and severity.
• Application technique: too little, too infrequent, or not covering the whole affected area.
• A moisturiser that stings the inflamed skin.
• An unrecognised trigger: a new detergent, a new pet, another allergen, or stress.
• A different diagnosis. Occasionally what looks like eczema is something else.

Treatment might include a short course of oral corticosteroids with oral antibiotics if the skin is infected. We may also refer you to a private dermatologist or via subsidised referral, depending on your preference and means. Rare severe cases may go to the emergency department for inpatient management.

When to come back and see us

If your plan isn’t working, coming in sooner usually gets better results. Book a consultation if:

• Your flare isn’t improving after about 2 weeks of the treatment we prescribed.
• You keep flaring in the same patches. Proactive therapy (twice-weekly maintenance) may suit you better than repeated courses.
• Your moisturiser stings on inflamed skin, or you’re unsure it’s still right.
• You have side effects from topical treatment: persistent burning or stinging, visible thinning, stretch marks, or unexplained changes.
• You’re worried about long-term steroid use, or think you may have topical steroid withdrawal.
• Sleep, school or work are significantly affected.

Urgent — come in (or go to an emergency department) today

These signs need same-day attention, not a routine appointment:

• Weeping skin, honey-coloured crusts or yellow pus on an eczema patch, suggesting bacterial infection
• Fever, feeling generally unwell, or rapidly spreading redness in an eczema area
• Sudden appearance of many small, dome-shaped blisters or punched-out sores on eczema skin. This may be eczema herpeticum, which is urgent.

For the full red-flag list for all ages, including more on eczema herpeticum in children, see Children with eczema — and when to call us.

Get in touch

Punggol — 658 Punggol East, #01-04, Singapore 820658 · Tel 6312 4589

Joo Chiat — 172 Joo Chiat Road, #01-01, Singapore 427443 · Tel 6920 1952

Email — admin@ktmc.sg

References

• Agency for Care Effectiveness (ACE). Mild and moderate atopic dermatitis (eczema) — a journey from flare to care. ACE Clinical Guideline, Ministry of Health, Singapore. February 2026. ace-hta.gov.sg
• American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol, 2023. jaad.org
• British Association of Dermatologists, British Dermatological Nursing Group, and National Eczema Society. Joint position statement on topical steroid withdrawal (2024).
• Hawro T et al. Safety and antipruritic efficacy of a menthol-containing moisturizing cream. J Dermatol Treat. 2018. PubMed

This information is for general education only and is not a substitute for medical advice. Flare severity, treatment choice, and dosing must be individualised — please attend a consultation for assessment. v1.1 · October 2026 (v1.0 April 2026) · Review due April 2028.