What are the prescription cream options for treating eczema?

Prescription Creams for Eczema

For adults with eczema, topical corticosteroids are the primary prescription treatment, with potency selection based on disease severity and body location, supplemented by topical calcineurin inhibitors (tacrolimus or pimecrolimus) for sensitive areas or maintenance therapy.

Topical Corticosteroids: First-Line Treatment

Potency Selection by Severity

Topical corticosteroids should be selected based on disease severity and anatomical location:

• Mild eczema: Hydrocortisone 1-2.5% (mild potency) 1
• Moderate eczema: Clobetasone butyrate 0.05% (Eumovate) or betamethasone valerate 0.025% (moderate potency) 1, 2
• Moderate-to-severe eczema: Betamethasone valerate 0.1%, mometasone 0.1% (potent) 1, 3
• Severe eczema: Clobetasol propionate 0.05% (very potent) 1

Potent and moderate topical corticosteroids are significantly more effective than mild potency steroids for moderate-to-severe eczema (70% vs 39% treatment success for potent vs mild; moderate-certainty evidence) 3. However, there is insufficient evidence that very potent corticosteroids provide additional benefit over potent formulations 3.

Application Frequency and Duration

Apply topical corticosteroids once daily rather than twice daily - this approach is equally effective for treating eczema flare-ups with potent corticosteroids (moderate-certainty evidence) 3, 4.

For acute flares: Use for 2-3 weeks short-term, then reassess 1. Treatment should continue until signs and symptoms resolve 1.

For maintenance therapy: Apply medium-potency topical corticosteroids twice weekly (weekend/proactive therapy) to previously affected areas to prevent relapses 1, 3. This reduces relapse rates from 58% to 25% (moderate-certainty evidence) 3.

Formulation Selection

• Ointments: Use for dry skin 1
• Creams: Use for weeping/moist skin 1

Location-Specific Recommendations

Face and neck: Use mild-to-moderate potency only (hydrocortisone 1-2.5% or clobetasone butyrate 0.05%) 1

Body/trunk/extremities: Can use potent corticosteroids (betamethasone valerate 0.1%, mometasone 0.1%) 1

Topical Calcineurin Inhibitors: Steroid-Sparing Alternatives

Tacrolimus Ointment

For adults with moderate-to-severe eczema, tacrolimus 0.1% ointment is strongly recommended (high-certainty evidence) 1. Tacrolimus 0.1% demonstrates superior efficacy compared to corticosteroid regimens, with 72.6% vs 52.3% achieving ≥60% improvement at 3 months 5.

Application: Twice daily to affected areas 1, 5

Pimecrolimus Cream

For adults with mild-to-moderate eczema, pimecrolimus 1% cream is strongly recommended (high-certainty evidence) 1.

Application: Twice daily to affected areas 1, 6

Key advantages: Particularly useful for sensitive areas (face, neck, intertriginous areas) where corticosteroid side effects are concerning 1.

Important Safety Considerations for Calcineurin Inhibitors

FDA black box warning exists regarding potential cancer risk, though long-term safety studies have not confirmed increased risk 1. Key restrictions include:

• Not approved for children under 2 years 6
• Use only on areas with active eczema 6
• Intended for short-term and intermittent use 6
• Avoid in immunocompromised patients 6
• Minimize sun exposure during treatment 6

Most common side effect: Skin burning/warmth at application site (52.4% with tacrolimus), typically mild-to-moderate and resolving within the first week 5, 6.

Combination Products

Corticosteroid-antimicrobial combinations are available but should be reserved for clinically infected eczema:

• Hydrocortisone 1% + fusidic acid 2% (Fucidin H) 1
• Betamethasone valerate 0.1% + fusidic acid 2% (Fucibet) 1
• Clobetasone 0.05% + oxytetracycline 3% + nystatin (Trimovate) 1

However, topical antimicrobials for routine eczema management are conditionally recommended against (low-certainty evidence) 1.

Newer Prescription Options

Ruxolitinib cream (JAK inhibitor) is strongly recommended for mild-to-moderate eczema in adults (moderate-certainty evidence) 1.

Crisaborole ointment (PDE-4 inhibitor) is strongly recommended for mild-to-moderate eczema in adults (high-certainty evidence) 1.

Common Pitfalls to Avoid

Steroid phobia: Appropriate short-term use of topical corticosteroids has minimal risk of skin thinning - only 26 cases identified among 2266 participants across 22 trials (1%), mostly with very potent formulations 3.

Twice-daily application: This provides no additional benefit over once-daily application for potent corticosteroids and increases medication waste 3, 4.

Abrupt discontinuation: After achieving control, transition to maintenance therapy (weekend application) rather than stopping completely to prevent relapses 3.

Inadequate quantities: Patients often under-apply topical treatments. For twice-weekly maintenance, adults require approximately 15-30g per 2 weeks for face/neck, 30-60g for both arms, 100g for both legs, and 100g for trunk 1.