Recommended Topical Medications for Eczema
Topical corticosteroids should be used as first-line therapy for eczema, with potency selected based on severity, followed by topical calcineurin inhibitors as second-line agents for maintenance therapy or steroid-sensitive areas. 1
First-Line Treatment: Topical Corticosteroids
Potency Selection
- Acute/severe flares: High-potency corticosteroids for 2-4 weeks 1, 2
- Moderate cases: Medium-potency corticosteroids for longer treatments 1
- Mild cases: Low-potency corticosteroids 1
- Sensitive areas (face, genitals, skin folds): Low-potency corticosteroids only 1, 3
Application Frequency
- Apply once daily for potent corticosteroids (similar efficacy to twice daily with fewer side effects) 2
- Treatment duration: 2-4 weeks for high-potency, up to 12 weeks for medium-potency 1, 3
- For maintenance: Consider weekend therapy (proactive approach) to prevent flares 2
Formulation Selection
- Ointments: Best for dry, lichenified lesions (better penetration)
- Creams: For most body areas, cosmetically acceptable
- Lotions/solutions: For hairy areas or scalp
Second-Line Treatment: Topical Calcineurin Inhibitors
Tacrolimus (Protopic)
- Tacrolimus 0.1%: For adults and children ≥2 years with moderate-to-severe eczema 1, 4
- Tacrolimus 0.03%: For children ≥2 years 1
- Apply twice daily until lesions clear 1
- Particularly useful for face, neck, and skin folds where steroid side effects are concerning 1, 4
Pimecrolimus (Elidel)
- Pimecrolimus 1%: For mild-to-moderate eczema in patients ≥2 years 5, 6
- Apply twice daily 5
- Less effective than moderate/potent corticosteroids and tacrolimus 0.1% 4, 6
- Important safety warning: Should not be used continuously for long periods due to theoretical concerns about malignancy risk 5
Third-Line Treatment: PDE-4 Inhibitors
Crisaborole
- For mild-to-moderate eczema
- Less effective than corticosteroids and calcineurin inhibitors 4
- May cause application site reactions 4
Emollients (Essential Adjunct Therapy)
- Apply liberally and frequently (3-8 times daily) 1
- Use even when skin appears normal 1
- Apply immediately after bathing to trap moisture 1
- Choose fragrance-free formulations 1
Treatment Algorithm
For acute flares:
- Start with appropriate potency topical corticosteroid based on severity and location
- Use once daily for 2-4 weeks
- Apply emollients frequently throughout the day
For maintenance therapy:
- Consider weekend therapy with topical corticosteroids to prevent flares 2
- OR switch to topical calcineurin inhibitors for steroid-sparing effect
- Continue regular emollient use
For steroid-resistant cases:
- Consider topical calcineurin inhibitors
- Evaluate for secondary infection
- Consider referral to dermatology
Important Precautions
Topical Corticosteroids
- Risk of skin thinning: Minimal with short-term use (under 3 weeks), increases with prolonged use 4, 7
- Monitor for: Telangiectasias, striae, atrophy (especially in thin-skinned areas) 1
- Patient education: Many patients have unfounded fears about topical steroids (72.5% worry about using them) 7
Topical Calcineurin Inhibitors
- Application site reactions: More common than with corticosteroids 4
- Burning sensation: Common initially but typically resolves within days 5, 4
- FDA warning: Avoid continuous long-term use due to theoretical malignancy risk 5
- Sun protection: Limit sun exposure during treatment 5
Special Populations
Children
- Use lower potency corticosteroids 1, 3
- Tacrolimus and pimecrolimus approved for children ≥2 years 1, 5
- Never use pimecrolimus in children under 2 years 5
Infected Eczema
- Treat clinically evident infections with appropriate antibiotics before starting anti-inflammatory treatment 1
- Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 1
- Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1
By following this evidence-based approach to topical therapy for eczema, clinicians can effectively manage symptoms while minimizing potential adverse effects.