Instead, treatment helps to reduce the symptoms of eczema (particularly itchiness) and establish long-lasting disease control (more than half of all children with eczema will outgrow it by the age of 12, though there is no cure for childhood eczema, either). The ultimate goal of treatment is to allow people with the condition to resume their normal daily functions at work, home, or school. Eczema treatment plans often include at-home skin-care routines, such as moisturizing the skin. “Daily moisturization can have a benefit in preventing an eczema flare, but may not be adequate once a flare occurs,” says Kanwaljit K. Brar, MD, a pediatric allergist and immunologist at NYU Langone in New York City. Prescription medications play a vital role in reducing inflammation and repairing the skin barrier. There are a number of different types of medications for atopic dermatitis, including:
Topical medications (creams, ointments, lotions) (1)Oral immunosuppressants (2,3)Self-administered injectable drugs
Corticosteroids, also known simply as steroids, are a first-line anti-inflammatory topical treatment for atopic dermatitis. (4) These drugs relieve itch and reduce inflammation; additionally, depending on the preparation, they can also help combat dry skin. Topical steroids come in various forms — ointments, creams, lotions, sprays, gels, and oils. They also come in various strengths, which range from class 1 (super potent) to class 7 (least potent). (1) Importantly, a higher steroid concentration does not necessarily mean higher potency, and the vehicles in which the drugs are prepared (creams versus lotions, for example) can also significantly impact strength. You can’t tell just by the name of the steroid how potent it is. (4) Class 1 (super potent) medications include: (1)
0.05 percent clobetasol propionate — Clobex (lotion, spray, shampoo), Olux E (foam), and Temovate E (emollient, cream, ointment, gel)0.05 percent halobetasol propionate — Ultravate (cream)0.1 percent fluocinonide — Vanos (cream)
Class 2 (potent) medications include:
0.05 percent diflorasone diacetate — ApexiCon E (cream)0.05 percent halobetasol propionate — Elocon (ointment)0.01 percent fluocinonide — Halog (ointment)0.25 percent desoximetasone — Topicort (cream, ointment)
Class 3 (upper mid-strength) medications include:
0.05 percent fluocinonide — Lidex-E (cream)0.05 percent desoximetasone — Topicort LP (cream)
Class 4 (mid-strength) medications include:
0.1 percent clocortolone pivalate — Cloderm (cream)0.1 percent mometasone furoate — Elocon (cream)0.1 percent triamcinolone acetonide — Aristocort A (cream) and Kenalog (ointment)0.1 percent betamethasone valerate — Valisone (ointment)0.05 percent desoximetasone — Topicort (cream, ointment)
Class 5 (lower mid-strength) medications include:
0.05 percent fluticasone propionate — Cutivate (cream, lotion)0.1 percent prednicarvate — Dermatop (cream)0.1 percent hydrocortisone butyrate — Locoid (cream, ointment)0.1 percent hydrocortisone probutate — Pandel (cream)0.1 percent triamcinolone acetonide — Kenalog (lotion)0.025 percent fluocinolone acetonide — Synalar (cream)
Class 6 (mild) medications include:
0.05 percent alclometasone dipropionate — Aclovate (cream, ointment)0.05 percent desonide — Verdeso (foam) and Desonate (gel)0.025 percent triamcinolone acetonide — Aristocort A (cream) and Kenalog (ointment)0.01 percent fluocinolone acetonide — Derma-Smoothe/FS (body or scalp oil)
Class 7 (least potent) medications include:
2/2.5 percent— Nutracort (lotion) and Synacort (cream)0.5–1 percent hydrocortisone — Cortaid (cream, spray, ointment)
These steroids should only be used intermittently to reduce inflammation, and they should be followed with a moisturizer. “Topical steroids do have side effects with prolonged use, such as skin thinning, stretch marks, and the development of telangiectasias [spider veins],” Dr. Brar says. Less commonly, they can also cause more serious side effects, including glaucoma and cataracts, adrenal suppression, and topical steroid addiction and withdrawal, among other things. (1) “However, they are currently the most effective treatment of skin inflammation and should be used under the guidance of an experienced doctor,” she adds. The drugs are typically prescribed when topical steroids are ineffective (though they are not necessarily more effective than steroids in general) or if a patient has eczema in areas that aren’t safe for long-term steroid use, such as the eyelids. (1,5) The two types of TCIs approved by the U.S. Food and Drug Administration (FDA) are tacrolimus (Protopic) and pimecrolimus (Elidel). (1) While TCIs don’t carry the same side effects as topical steroids, they may cause a mild burning or stinging sensation when first applied. In 2005, the FDA added a box warning for TCIs because of a potential increased risk of lymphoma. (5) But a literature review of more than 3,000 studies published in the Journal of the American Academy of Dermatology found that while there is a modest increased risk of lymphoma in people with severe atopic dermatitis, that risk does not appear to be tied to TCI use. (6) Another type of topical medication for eczema approved by the FDA is crisaborole (Eucrisa). It is in a class of drugs known as PDE4 inhibitors that work by blocking the enzyme phosphodiesterase 4, which is involved in the body’s inflammatory processes. (1,7) In clinical trials, Eucrisa helped patients get clear or almost clear skin after 28 days of treatment. Serious side effects include hypersensitivity reactions to Eucrisa’s active ingredient, crisaborole. The most common side effect is application site pain, including burning or stinging. More recently, ruxolitinib (Opzelura), the first topical JAK inhibitor – a class of drugs which limit cytokines (immune system messengers in the blood and skin that are linked to inflammation) was approved by the FDA for eczema. The cream is approved for short-term, non-continuous treatment of mild to moderate eczema. Patients with active, serious infection should avoid using ruxolitinib. Non-melanoma skin cancers including basal cell and squamous cell carcinoma have occurred in patients treated with Opzelura. In addition, Opzelura should be used with caution in patients who may be at increased risk of thrombosis. Immunosuppressants work by preventing the body’s immune system from activating the inflammatory skin response that’s the hallmark of atopic dermatitis, resulting in less itching, inflammation, and skin barrier problems. (8) The most commonly used immunosuppressants for atopic dermatitis are cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil. When used for atopic dermatitis, immunosuppressants are considered “off-label” because they are not approved by the FDA to specifically treat the condition. Though they are effective for some people, these systemic steroids are not advised for long-term use. The drugs carry a number of potentially serious side effects, including increased risk of certain cancers, increased blood pressure (cyclosporine), increased risk of kidney damage (cyclosporine and methotrexate), and risk of liver damage (methotrexate). Biologic drugs, or biologics, are another type of systemic medication prescribed for atopic dermatitis. (9) The drugs work by blocking the activity of the protein interleukin, which normally helps the immune system fight off pathogens with inflammation but is triggered erroneously (and without the presence of pathogens) in people with atopic dermatitis and other inflammatory conditions. Dupilumab (Dupixent) is the first biologic approved for the treatment of atopic dermatitis. In clinical trials, more than half of people who took Dupixent — which is injected under the skin every other week — had their symptoms reduced by 75 percent over the course of 16 weeks. In 2020 the FDA expanded its approval of Dupixent to children who are 6 years old and above. Side effects for the biologic include:
Ocular issues, such as conjunctivitis (pink eye)Injection site reactionsCold sores on the mouth or lips
Tralokinumab-ldrm (Adbry) is another biologic that has been approved for adults with moderate to severe atopic dermatitis. Adbry, which is injected every other week for the first 16 weeks of treatment and then injected every four weeks, can be used with or without topical corticosteroids. Side effects include:
Inflammation of the eye and eyelidReaction at the injection siteHigh count of a certain white blood cell (eosinophilia)
A new class of oral medication approved for treatment of moderate to severe atopic dermatitis are the JAK inhibitors, upadacitinib (Rinvoq) and abrocitinib (Cibinqo). The FDA has placed a box warning on these three medications for potentially increasing the risk for all-cause mortality, serious infections, certain cancers (including lymphoma), heart attack, stroke, and thrombosis (blood clots). Rinvoq and Cibinqo are not recommended for use in combination with other JAK inhibitors, biologics, or other immunosuppressants. You should not breastfeed while taking abrocitinib or upadacitinib. Antihistamines can help relieve itching in the case of hives and other allergic conditions, but the drugs don’t relieve itching associated with atopic dermatitis, because the underlying cause is different. Instead, classical antihistamines, which cause drowsiness and are the active ingredient in over-the-counter sleep aids, are occasionally used to help people with atopic dermatitis get a better night’s sleep. People with atopic dermatitis are at an increased risk of infections, especially bacterial skin infections from staphylococcus and streptococcus bacteria. (10) These infections worsen eczema symptoms and must be treated with antibiotics, such as cephalexin (Keflex) or dicloxacillin, before eczema can be brought back under control. (5)
