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How to Find the Right Topical Treatment For Your Eczema

Posted on August 05, 2022

  • Choosing the right topical treatment for atopic eczema depends on many factors, like the severity of your symptoms, potential side effects, location and size of the affected areas, and age.
  • Prescription treatment options for mild, moderate, or severe eczema include topical steroids, topical calcineurin inhibitors (TCIs), phosphodiesterase 4 (PDE4) inhibitors, and Janus kinase (JAK) inhibitors.
  • The effectiveness of a prescription topical will vary from person to person, so it’s important to work with your dermatologist to experiment and find the best treatment for you.

For people living with atopic eczema (also called atopic dermatitis), choosing the right prescription topical treatment can be overwhelming. There are several types available, and each has its own pros and cons to consider.

Members of MyEczemaTeam, the online support network for people with eczema, have shared their frustrations with finding an effective eczema treatment. One member said, “I seriously find that you have to go between products that work, and start experimenting with them until you find a good combination.”

Another wrote, “Although I have literally battled eczema for years, I have been increasingly frustrated by the ever-growing number of ointments and creams, and have never really understood the differences. I am taking all 10 tubes to the dermatologist for a discussion.”

Several factors affect which prescription topical treatment option is best for your atopic dermatitis, including:

  • The severity of your eczema symptoms
  • Treatment side effects
  • The site and size of the affected areas
  • Your age

Each case of eczema is different, and a treatment that works best for one person may not work for another. You should work with your dermatology care provider to determine which treatment best suits your individual needs. You should also keep them informed if a treatment isn’t working the way you’d hoped or is causing unwanted side effects. Remember, though, that to accurately determine whether or not a treatment is a good fit, it’s important to stick to your treatment plan and practice consistent skin care techniques.

This article will help you compare your prescription eczema treatment options and discuss them with your doctor. To learn more about topical eczema treatment options, check out MyEczemaTeam’s Guide to Topical Eczema Treatments.

Choosing Topical Treatments Based on Severity of Symptoms

When choosing a topical therapy for atopic dermatitis, it’s important to consider the severity of your symptoms. Prescription treatments approved by the U.S. Food and Drug Administration (FDA) are available for mild, moderate, or severe atopic dermatitis.

JAK Inhibitors

Topical JAK inhibitors are a new type of medication suited for the targeted treatment of mild to moderate eczema. They work by blocking inflammation pathways of the immune system that contribute to itching and skin barrier dysfunction in eczema. As a new type of treatment, they offer an option for people that haven’t had success managing their eczema through other treatment methods.

In late 2021, ruxolitinib (Opzelura) became the first topical JAK inhibitor to get FDA approval for the treatment of atopic dermatitis. While other topical JAK inhibitors are being developed to treat eczema, Opzelura is the only topical JAK inhibitor currently available by prescription.

Opzelura is approved for short-term, noncontinuous treatment of mild to moderate atopic dermatitis. It’s suited for people with the following characteristics:

  • Aged 12 and older
  • Not immunocompromised
  • Have eczema symptoms that aren’t well-controlled with other treatment options or are unable to use other options (due to issues like allergic reactions to other medications)

Steroids

Topical steroids, also called topical corticosteroids, may be prescribed for mild, moderate, or severe atopic dermatitis symptoms. They are the oldest and most commonly prescribed topical atopic dermatitis treatments. Corticosteroids work by decreasing the inflammation caused by the overactive pathways that contribute to atopic dermatitis. Examples include betamethasone, hydrocortisone, and triamcinolone.

The potency of a particular topical steroid depends on its type and concentration. Different steroids have different levels of potency, so they can’t be compared apples to apples based on the percentage of active ingredients they contain. For example, betamethasone 0.05 percent and desonide 0.05 percent have the same concentration, but betamethasone is a class 1 super potent corticosteroid whereas desonide is a class 6 low-potency corticosteroid.

Your health care provider will recommend a potency level based on factors including the severity of your symptoms, which area is affected, and the size of that area. To prevent unwanted side effects, it’s best to use the lowest potency necessary to treat the symptoms. Lower-potency steroids are better for delicate skin areas like the face, or when treatment is needed for a larger area of the body.

On the other hand, higher-potency steroids are usually used only for severe symptoms or on areas with thick skin, such as feet and hands. More potent steroids are better at reducing inflammation but are also more likely to thin out the skin or be absorbed systemically into the bloodstream.

TCIs

Topical calcineurin inhibitors are anti-inflammatory medications. They act as immunosuppressants, meaning they work by suppressing the immune system. This can help relieve inflammation, itchy skin, dryness, and discoloration. TCIs effectively act as topical steroids — without the side effect of causing atrophy (thinning) of the skin.

TCIs are usually second-line treatments for mild, moderate, or severe cases of atopic dermatitis. A doctor may prescribe them if topical steroids are not effective. They may also recommend them as maintenance medication, since they do not thin out the skin.

Pimecrolimus cream (Elidel) and tacrolimus ointment (Protopic) are the two TCIs currently available by prescription. Elidel is approved by the FDA to treat mild to moderate atopic dermatitis. Protopic is approved for moderate to severe atopic dermatitis.

PDE4 Inhibitors

Topical PDE4 inhibitors are a newer type of topical medication for mild to moderate atopic dermatitis. They work by blocking inflammation pathways of the immune system that contribute to eczema. Eucrisa, a formulation of crisaborole, is the only FDA-approved PDE4 inhibitor currently available by prescription. It’s approved for the treatment of mild to moderate atopic dermatitis. This treatment contains no steroids, so it doesn’t thin out the skin, and it can be used on more sensitive areas.

Comparing Side Effects

Topical treatments come with the risk of unwanted side effects, which vary from type to type. If the side effects from a particular treatment are bothersome, reach out to your health care provider to ask whether there may be a more tolerable treatment available for your specific diagnosis.

Topical Steroids

Side effects of topical steroids relate to the potency of the steroid, the area to which it’s applied, and how long it’s used. Higher potency, application on larger areas of the body or on thinner skin, and long-term use are associated with a higher risk of side effects.

The most common side effects include:

  • Thinning of the skin
  • Stretch marks
  • Easy bruising
  • Small spots that appear on the skin as a result of bleeding
  • Rosacea — A condition characterized by skin discoloration (red, purple, or brown, depending on skin tone) and bumps
  • Worsening acne

The effectiveness of a topical steroid can decrease over time as a person builds up a tolerance.

Systemic side effects (those that affect the entire body) can occur when topical steroids are absorbed into the body. The risk is greater with higher-potency steroids, application over a large area of the body, or prolonged use.

Systemic side effects include:

  • Hypothalamic-pituitary axis suppression, which can weaken immune responses to infection
  • Cushing syndrome — A rare hormonal disorder
  • Glaucoma — Eyes diseases that can cause vision loss or blindness
  • High blood pressure
  • High blood sugar

If you stop using a topical steroid, you may experience withdrawal or rebound symptoms. Talk to your medical provider about discontinuing topical steroid treatment.

TCIs

The most common side effects of TCIs are itching and burning. Usually, these go away on their own after a few days of treatment. TCIs can also cause sun sensitivity, so it’s best to minimize sun exposure and wear sunscreen if you are using a TCI.

Other possible side effects include:

  • Skin discoloration
  • Warm or tingly sensations
  • Blocked skin pores
  • Viral infections, such as warts or cold sores

If used over large body surface areas, TCIs can be absorbed and systemically suppress the immune system.

PDE4 Inhibitors

The most common side effect of crisaborole is pain at the application site, such as burning or stinging. This may be reduced by mixing it with a moisturizer.

JAK Inhibitors

Some of the most common side effects of ruxolitinib include:

  • Nose and throat inflammation
  • Diarrhea
  • Bronchitis
  • Ear infection
  • Rash

Age Considerations for Topical Treatments

When considering topical treatments for atopic dermatitis, age is an important factor. Not all treatments are appropriate for babies and young children. The following are some important things to know about age when choosing a topical eczema treatment.

Topical Steroids

Topical steroids are more likely to absorb systemically in babies and young children and cause unwanted side effects. This is because, compared to adults, they have a larger skin surface area relative to their body weight. Therefore, lower-potency topical steroids are preferred for pediatric use in babies and young children, especially when a large area of the body is affected.

TCIs

Tacrolimus and pimecrolimus should not be used in children under 2. Tacrolimus is available in 0.03 percent or 0.1 percent. Only the lower-potency formulation of tacrolimus, 0.03 percent, is approved for adults and children aged 2 to 15 years. The higher-potency 0.1 percent should only be used for people 16 years or older.

PDE4 Inhibitors

Eucrisa is approved for use in adults and children ages 3 months or older.

JAK Inhibitors

Opzelura is approved for use in adults and children 12 years and older.

Body Site and Size of Affected Areas

The body site, or location of the body to be treated, is an important factor to consider when selecting a topical treatment for atopic dermatitis. For example, if you need treatment for a delicate skin area, such as your face, you’ll want to be careful with your treatment choice. Additionally, if a large surface area of your body is affected, you’ll need to apply more of a particular topical, which can mean more side effects.

Topical Steroids

Many different formulations of topical steroids are available, including ointments, creams, lotions, gels, foams, and sprays. Each has its advantages and disadvantages, and some factors depend on personal preference. For example:

  • Ointments don’t rub into the skin, and they tend to have a greasy feel but allow the skin to retain moisture.
  • Creams are less greasy so they can absorb more easily into the skin, but they may contain preservatives that aggravate atopic dermatitis.
  • Lotions may be easier to use in areas where hair grows because the higher moisture content of lotion makes it easier to absorb into the skin, but lotions may not hydrate the skin as well.
  • Gels and foams may feel less messy in areas where hair grows, compared to an ointment or cream.

When a large area of skin needs treatment, a lower-potency topical steroid is recommended to minimize how much is absorbed systemically. Lower potencies are also recommended for delicate skin areas such as the face or genital area, or areas where skin rubs together such as between the thighs or under the breasts.

Higher-potency formulations might be more appropriate for areas of thicker skin, such as the feet and hands. If an area needs to be bandaged, a lower-potency treatment is preferred because bandaging will increase absorption of the steroid.

TCIs

An advantage of TCIs is that they can be used for sensitive areas, such as the skin on the face, whereas topical steroids are more likely to cause thinning of the skin. They can also be used by people ages 2 and up.

PDE4 Inhibitors

PDE4 inhibitors are newer treatments, and they have few restrictions recommended by the manufacturers as to where they can be applied on the body. Use in the eyes, mouth, or genitals is not recommended.

JAK Inhibitors

Like PDE4 inhibitors, JAK inhibitors are relatively new and similarly few restrictions insofar as where they can be applied. Ruxolitinib should only be applied twice daily to a maximum of 20 percent of the body surface area. If a large body area is affected, another treatment may be more appropriate.

Talk With Others Who Understand

MyEczemaTeam is the social network for people with eczema and their loved ones. On MyEczemaTeam, more than 43,000 members come together to ask questions, give advice, and share their stories with others who understand life with eczema.

Are you choosing between topical eczema treatments? Have you found what works best for you? Share your experience in the comments below, or start a conversation by posting on your Activities page.

All updates must be accompanied by text or a picture.

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