From the Guidelines
Severe eczema treatment should prioritize a combination of topical and systemic therapies, with a focus on reducing inflammation, repairing the skin barrier, and modulating the overactive immune response. The most recent and highest quality study 1 suggests that for severe cases, topical corticosteroids like clobetasol propionate 0.05% or betamethasone dipropionate 0.05% applied twice daily for 1-2 weeks during flares are often the first line of treatment. Some key points to consider when treating severe eczema include:
- Using topical corticosteroids on affected areas only and tapering once improvement occurs to prevent side effects
- Utilizing topical calcineurin inhibitors such as tacrolimus 0.1% ointment or pimecrolimus 1% cream for sensitive areas like the face
- Considering oral immunosuppressants, including cyclosporine (2.5-5 mg/kg/day), methotrexate (7.5-25 mg weekly), or azathioprine (1-3 mg/kg/day) for systemic treatment
- Exploring newer biologic medications like dupilumab (300 mg subcutaneous injection every two weeks after a 600 mg loading dose) for severe cases
- Implementing phototherapy using narrowband UVB three times weekly for 6-12 weeks as an effective treatment option
- Emphasizing daily skin care, including gentle, fragrance-free cleansers and liberal use of thick emollients like petroleum jelly or ceramide-containing moisturizers applied immediately after bathing
- Avoiding triggers, wearing cotton clothing, maintaining optimal humidity, and using antihistamines like hydroxyzine (10-25 mg three times daily) for itch control as important supportive measures. It is essential to note that the decision to initiate these more advanced therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of eczema, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.
From the FDA Drug Label
DUPIXENT is a prescription medicine used: to treat adults and children 6 months of age and older with moderate-to-severe eczema (atopic dermatitis or AD) that is not well controlled with prescription therapies used on the skin (topical), or who cannot use topical therapies DUPIXENT can be used with or without topical corticosteroids.
The treatment for severe eczema is dupilumab (DUPIXENT), which can be used with or without topical corticosteroids.
- Key points:
From the Research
Treatment Options for Severe Eczema
- Basic therapy for severe eczema consists of hydrating topical treatment and avoidance of specific and unspecific provocation factors 3
- Anti-inflammatory treatment for acute eczematous skin lesions mainly includes topical glucocorticoids and topical calcineurin inhibitors (tacrolimus and pimecrolimus) 3, 4
- Systemic anti-inflammatory therapy is limited to severe cases and consists of systemic steroids, cyclosporine A, or mycophenolate mofetil 3, 5
- Proactive therapy, which involves long-term, low-dose intermittent application of anti-inflammatory therapy to previously affected skin, is a novel concept for preventing flares and stabilizing the skin barrier 4, 6
Topical Corticosteroids
- Potent and moderate topical corticosteroids are probably more effective than mild topical corticosteroids, primarily in moderate or severe eczema 7
- There is uncertain evidence to support any advantage of very potent over potent topical corticosteroids 7
- Applying potent topical corticosteroids only once a day probably does not decrease the number achieving treatment success compared to twice daily application 7
Systemic Treatment
- Cyclosporine is recommended as the first option for patients with atopic eczema refractory to conventional treatment 5
- Evidence from randomized controlled trials also exists for interferon-γ and azathioprine 5
- Systemic glucocorticosteroids have not been assessed adequately in studies, despite being frequently used in clinical practice 5
- Mycophenolate mofetil showed effectiveness in small uncontrolled studies 5