What are the recommended topical creams for treating eczema?

Recommended Topical Creams for Treating Eczema

For treating eczema, a stepwise approach beginning with topical corticosteroids as first-line treatment is strongly recommended, with topical calcineurin inhibitors, PDE-4 inhibitors, and JAK inhibitors as alternative or adjunctive therapies depending on severity, location, and response. 1

First-Line Topical Treatments

Topical Corticosteroids (TCS)

• Potency selection based on severity and location:

  • Mild eczema: Low-potency (Class 6-7) TCS
  • Moderate eczema: Medium-potency (Class 3-5) TCS
  • Severe eczema: High-potency (Class 1-2) TCS 1
  • For sensitive areas (face, genitals, skin folds): Low-potency TCS

• Application recommendations:

  • Apply twice daily for acute flares for up to 4 weeks initially 1
  • Once-daily application is as effective as twice-daily for potent corticosteroids 2
  • After improvement, reduce to 1-2 times weekly (proactive therapy) to prevent flares 1
  • Weekend therapy (proactive approach) significantly reduces relapse rates from 58% to 25% 2

• Safety considerations:

  • Monitor for skin atrophy, striae, telangiectasia, and purpura 1
  • Short-term use of even potent TCS shows low risk of skin thinning (only 1% across 22 trials) 2
  • Long-term intermittent use for up to 5 years shows reassuring safety data regarding skin thinning and growth 3

Topical Calcineurin Inhibitors (TCIs)

• Recommended for:

  • Sensitive areas (face, neck, skin folds) where skin atrophy is a concern 1
  • Patients with steroid phobia 4
  • Long-term maintenance therapy 1

• Available options:

  • Tacrolimus 0.1% (for adults) and 0.03% (for children) ointment
  • Pimecrolimus 1% cream (for patients ≥2 years old) 5

• Application recommendations:

  • Apply twice daily until symptoms improve
  • May cause burning/stinging sensation initially, which typically resolves within days 5

• Safety considerations:

  • No risk of skin atrophy, making them suitable for long-term use 1
  • FDA black box warning exists regarding theoretical malignancy risk, though no signal has emerged 4, 5
  • Should not be used in patients under 2 years of age 5

Newer Topical Options

• PDE-4 inhibitors (e.g., crisaborole 2%):

  • Recommended for mild to moderate eczema 1
  • May cause application site reactions 6

• Topical JAK inhibitors:

  • Highly effective for mild to moderate eczema 1
  • Ruxolitinib 1.5% and delgocitinib 0.5% or 0.25% rank among most effective topical treatments 6

Treatment Algorithm

1. Initial assessment of severity:

   • Mild: Limited areas, minimal impact on quality of life
   • Moderate: More extensive involvement, moderate impact on quality of life
   • Severe: Widespread involvement, significant impact on quality of life 4

2. For mild eczema:

   • Start with low-potency TCS (e.g., hydrocortisone 1%) twice daily for 1-2 weeks
   • For sensitive areas: Consider TCIs or low-potency TCS
   • If inadequate response: Move to moderate-potency TCS

3. For moderate eczema:

   • Start with moderate-potency TCS twice daily for 2-4 weeks
   • For sensitive areas: Use TCIs
   • If inadequate response after 2 weeks: Consider short-term high-potency TCS

4. For severe eczema:

   • Start with high-potency TCS twice daily for up to 4 weeks
   • For sensitive areas: Use TCIs
   • If inadequate response after 4-6 weeks of optimized topical therapy: Consider referral for systemic therapy 4, 1

5. Maintenance therapy:

   • After clearing: Switch to proactive therapy (weekend application of TCS or TCIs) to prevent flares 2
   • Continue daily emollient use even when skin appears normal 1

Emollients and Skin Care

• Apply emollients 3-8 times daily, even when skin appears normal 1
• Apply immediately after bathing to lock in moisture 1
• Choose formulations based on patient preference and season:
  • Ointments: Maximum occlusion, best for very dry skin or winter
  • Creams: Less greasy, good balance of hydration and acceptability
  • Lotions: Lightest, good for hairy areas but least moisturizing 1

Common Pitfalls to Avoid

1. Undertreatment:

   • Using too low potency TCS for severity
   • Insufficient duration of treatment
   • Inadequate amounts applied 7

2. Steroid phobia:

   • Address concerns about TCS side effects with education
   • Explain that short-term use of appropriate potency TCS has low risk of adverse effects 4, 3

3. Inappropriate use of antibiotics:

   • Avoid routine use of topical or oral antibiotics for non-infected eczema 7
   • Only use antimicrobials when clinical infection is present 1

4. Ineffective treatments:

   • Avoid routine use of oral antihistamines for eczema symptoms 7
   • Silk clothing, ion-exchange water softeners, and emollient bath additives have not shown benefit 7

5. Ignoring triggers:

   • Identify and eliminate irritants (detergents, perfumes, alcohol-based products)
   • Consider environmental modifications (air purifiers, humidity control) 1

By following this evidence-based approach to topical therapy for eczema, clinicians can effectively manage symptoms, minimize adverse effects, and improve patients' quality of life.