What are the treatment options for atopic dermatitis (eczema)?

From the Guidelines

Eczema treatment should prioritize the use of topical corticosteroids, with the least potent preparation required to keep the eczema under control, as well as emollients and trigger avoidance, and for severe cases, consider phototherapy or systemic therapies such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment of eczema typically involves a combination of moisturizing, topical medications, and trigger avoidance.

• Start with regular application of thick moisturizers like petroleum jelly, CeraVe, or Eucerin immediately after bathing to lock in moisture.
• For mild flares, use over-the-counter 1% hydrocortisone cream twice daily for up to two weeks.
• More severe cases may require prescription-strength topical corticosteroids like triamcinolone 0.1% or fluocinonide 0.05%, applied thinly to affected areas twice daily for 1-2 weeks.

Systemic Therapies

For severe cases unresponsive to topical treatments, consider phototherapy or systemic therapies, with the decision to initiate these more advanced therapies made using shared decision-making between patients and clinicians, taking into account the severity of AD, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.

• Oral medications like prednisone, cyclosporine, or dupilumab (Dupixent) injections may be prescribed by a dermatologist.
• New evidence supports strong recommendations for the use of biologics and Janus kinase inhibitors, such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib 1.

Important Considerations

• The use of topical anti-inflammatory medications concomitantly with phototherapy and systemic therapies is common in clinical practice 1.
• Identify and avoid triggers such as harsh soaps, certain fabrics, stress, and allergens.
• Antihistamines like diphenhydramine (Benadryl) can help reduce itching, especially at night.
• The long-term safety of systemic medications for AD should be continuously monitored with rigorous pharmacovigilance studies 1.

From the FDA Drug Label

ELIDEL Cream is a prescription medicine used on the skin (topical) to treat eczema (atopic dermatitis). ELIDEL Cream is for adults and children age 2 years and older who do not have a weakened immune system. Use ELIDEL Cream only on areas of your skin that have eczema. Use ELIDEL Cream for short periods, and if needed, treatment may be repeated with breaks in between.

Eczema Treatment with Pimecrolimus (TOP): Pimecrolimus cream 1% is used to treat mild to moderate atopic dermatitis (eczema) in adults and children aged 2 years and older.

• Apply a thin layer of ELIDEL Cream only to the affected skin areas, twice a day, as directed by the doctor.
• Use the smallest amount of ELIDEL Cream needed to control the signs and symptoms of eczema.
• Stop ELIDEL Cream when the signs and symptoms of eczema go away, or as directed by the doctor. 2, 2, 2

From the Research

Eczema Treatment Options

• Topical corticosteroids are a first-line treatment for eczema, with potent and moderate topical corticosteroids being more effective than mild topical corticosteroids, primarily in moderate or severe eczema 3
• The effectiveness of topical corticosteroids is similar between once daily and twice daily (or more) frequent use to treat eczema flare-ups 3
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 3
• Topical anti-inflammatory treatments, such as potent and/or very potent topical steroids, tacrolimus 0.1%, and ruxolitinib 1.5%, are ranked among the most effective treatments for improving patient-reported symptoms and clinician-reported signs 4

Application and Usage

• Correct patient application is critical to successful use of topical corticosteroids, and patients may be taught application using the fingertip unit method 5
• The quantity of corticosteroid prescribed depends on the duration of treatment, the frequency of application, the skin location, and the total surface area treated 5
• Topical corticosteroids can be applied once or twice per day for up to three weeks for super-high-potency corticosteroids or up to 12 weeks for high- or medium-potency corticosteroids 5

Safety and Adverse Effects

• Local adverse events, such as abnormal skin thinning, are not well reported and come largely from low- or very low-certainty, short-term trials 3
• The risk of adverse effects increases with prolonged use, a large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals 5
• Intermittent use of topical corticosteroids probably results in little to no difference in risk of growth abnormalities, non-skin infections, impaired vaccine response, and lymphoma/non-lymphoma malignancies 6
• Topical corticosteroids use probably results in little to no difference in skin thinning when used intermittently to treat flares 6

Other Treatment Options

• Maintenance therapy for atopic dermatitis consists of liberal use of emollients and daily bathing with soap-free cleansers 7
• Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment 7
• Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 7
• Newer medications, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost-prohibitive for most patients 7