What topical cream is recommended for skin conditions?

Topical Cream Recommendations for Skin Conditions

For atopic dermatitis in adults, use topical corticosteroids as first-line therapy, with tacrolimus 0.03-0.1% ointment or pimecrolimus 1% cream as steroid-sparing alternatives, and consider ruxolitinib cream or crisaborole ointment for mild-to-moderate disease. 1

Atopic Dermatitis (Eczema)

First-Line Treatment

• Topical corticosteroids (TCS) are the most commonly utilized FDA-approved therapy and are strongly recommended with high certainty evidence for mild-to-severe atopic dermatitis 1
• TCS are grouped into 7 classes by potency (Class I = very high potency, Class VII = very low potency) 1
• Potency selection depends on anatomical site: use lower potency agents (hydrocortisone 1-2.5%) on face, neck, genitals, and body folds; medium-to-high potency on trunk and extremities 1, 2
• Apply once or twice daily for up to 3 weeks for super-high-potency corticosteroids or up to 12 weeks for high- or medium-potency corticosteroids 2

Steroid-Sparing Alternatives

• Tacrolimus 0.03% or 0.1% ointment: strongly recommended with high certainty evidence for adults with atopic dermatitis 1
• Pimecrolimus 1% cream: strongly recommended with high certainty evidence for adults with mild-to-moderate atopic dermatitis 1
• These topical calcineurin inhibitors are particularly valuable when there is concern for adverse events from prolonged corticosteroid use 1
• The FDA black box warning regarding cancer risk with topical calcineurin inhibitors is likely not clinically meaningful given the low absolute risk of lymphoma 1

Newer Non-Steroidal Options

• Ruxolitinib cream: strongly recommended with moderate certainty evidence for adults with mild-to-moderate atopic dermatitis 1
• Crisaborole ointment: strongly recommended with high certainty evidence for adults with mild-to-moderate atopic dermatitis 1

Maintenance Therapy

• Intermittent use of medium-potency topical corticosteroids (2 times per week) is strongly recommended to reduce disease flares and relapse 1

Acne Vulgaris

Topical Therapy Options

• Benzoyl peroxide (with or without erythromycin or clindamycin combinations) is recommended as monotherapy for mild acne or in conjunction with topical retinoids or systemic antibiotics for moderate-to-severe acne 1
• Topical retinoids (adapalene, tretinoin) are recommended as monotherapy for primarily comedonal acne or in combination with topical/oral antimicrobials for inflammatory acne 1
• Topical dapsone 5% gel is recommended for inflammatory acne, particularly in adult females 1
• Azelaic acid is recommended as adjunctive treatment and for postinflammatory dyspigmentation 1
• Topical antibiotics alone are NOT recommended as monotherapy due to bacterial resistance risk 1

Drug-Induced Skin Reactions (EGFR Inhibitors, Checkpoint Inhibitors)

Papulopustular Rash Management

• Grade 1 (mild): Continue therapy; apply topical corticosteroids (clobetasol propionate for body, hydrocortisone 2.5% or alclometasone 0.05% for face) twice daily plus oral antihistamines 1
• Grade 2 (moderate): Continue therapy; escalate topical corticosteroid potency and initiate oral tetracycline antibiotics (doxycycline 100 mg twice daily or minocycline 100 mg once daily) for at least 6 weeks 1
• Grade 3 (severe): Hold immunotherapy; use systemic corticosteroids (prednisone 0.5-1 mg/kg/day) along with topical steroids and oral antibiotics 1

Xerosis and Pruritus

• Apply alcohol-free moisturizers with urea (5-10%) at least twice daily 1
• For pruritus: use polidocanol-containing lotions and oral H1-antihistamines (cetirizine, loratadine, fexofenadine) 1
• Topical corticosteroids (prednicarbate cream 0.02% for body, hydrocortisone for face) for inflammatory eczematous changes 1

Impetigo

• Mupirocin ointment 2% is FDA-indicated for topical treatment of impetigo due to Staphylococcus aureus and Streptococcus pyogenes 3

Critical Safety Considerations

Corticosteroid Adverse Effects

• Risk of atrophy, striae, rosacea, telangiectasias increases with prolonged use, large application areas, higher potency, occlusion, and application to thin skin areas 2
• Hydrocortisone 1% cream can cause transient epidermal thinning after only 2 weeks of continuous use 4
• In children, use lower potencies and shorter durations 2
• No specified time limit exists for low-potency topical corticosteroids 2

Application Technique

• Use the fingertip unit method: one fingertip unit (from tip of index finger to distal interphalangeal joint crease) covers approximately 2% body surface area in adults 2
• For atopic dermatitis, apply moisturizers at least twice daily before considering active treatments 1

What to Avoid

• Do NOT use topical antihistamines for atopic dermatitis (conditionally recommended against) 1
• Do NOT use topical antimicrobials as monotherapy for atopic dermatitis (conditionally recommended against) 1
• Avoid greasy occlusive creams for drug-induced acneiform rash as they may facilitate folliculitis 1
• Avoid topical acne medications (benzoyl peroxide, salicylic acid) for EGFR inhibitor-induced rash as they worsen irritation 1