What creams are recommended for treating eczema?

Recommended Creams for Eczema

For adults with eczema, topical corticosteroids are the first-line treatment, with potent or moderate-potency formulations applied once daily being most effective for active disease, while tacrolimus 0.1% ointment or pimecrolimus 1% cream serve as steroid-sparing alternatives particularly for sensitive areas like the face. 1

First-Line Treatment: Topical Corticosteroids

Topical corticosteroids remain the cornerstone of eczema treatment with strong evidence supporting their use. 1

Potency Selection Based on Disease Severity

• Potent topical corticosteroids (e.g., betamethasone valerate 0.1%, mometasone 0.1%) are significantly more effective than mild corticosteroids for moderate-to-severe eczema, with 70% vs 39% achieving treatment success 2, 3
• Moderate-potency corticosteroids (e.g., clobetasone butyrate 0.05%) show better efficacy than mild preparations, with 52% vs 34% achieving clearance 2
• Mild corticosteroids (e.g., hydrocortisone 1%) are appropriate for facial application and mild disease 1
• Very potent corticosteroids (e.g., clobetasol propionate 0.05%) show uncertain additional benefit over potent formulations and should be reserved for short courses in severe disease 2, 3

Application Frequency

Once-daily application of potent topical corticosteroids is equally effective as twice-daily application, eliminating the need for more frequent dosing 1, 2. This finding is based on moderate-certainty evidence from 15 trials involving 1,821 participants 2.

Maintenance Therapy

Intermittent use of medium-potency topical corticosteroids twice weekly (weekend or "proactive" therapy) is strongly recommended to prevent flares, reducing relapse rates from 58% to 25% 1, 2. This approach should be applied to previously affected areas even after clearance 1.

Second-Line Treatments: Topical Calcineurin Inhibitors

Tacrolimus Ointment

Tacrolimus 0.1% or 0.03% ointment is strongly recommended for adults with eczema, particularly when corticosteroid side effects are a concern 1. The American Academy of Dermatology provides high-certainty evidence for this recommendation 1.

• Tacrolimus 0.1% ranks among the most effective treatments, comparable to potent corticosteroids 3
• Particularly useful for facial and intertriginous areas where steroid atrophy risk is higher 1
• Common side effect: burning sensation at application site (occurs in approximately 2.2 times more frequently than vehicle) 3

Pimecrolimus Cream

Pimecrolimus 1% cream is strongly recommended for adults with mild-to-moderate eczema based on high-certainty evidence 1.

• Significantly improves disease severity within 7 days, with 53% vs 20% achieving IGA improvement 1
• Reduces itch scores: 81% vs 63% achieved meaningful itch reduction 1
• Less effective than moderate or potent corticosteroids and tacrolimus 0.1% 3, 4
• May reduce flares and decrease need for topical corticosteroid use 1
• Application-site burning is the most common side effect 5, 3

Important FDA safety consideration: While a black box warning exists regarding potential cancer risk, long-term safety studies suggest the absolute risk is very low and likely not clinically meaningful 1, 5

Newer Topical Agents

JAK Inhibitors

Ruxolitinib 1.5% cream is strongly recommended for adults with mild-to-moderate eczema based on moderate-certainty evidence 1. Network meta-analysis ranks it among the most effective treatments, comparable to potent corticosteroids 3.

PDE-4 Inhibitors

Crisaborole 2% ointment is strongly recommended for adults with mild-to-moderate eczema based on high-certainty evidence 1. However, it ranks among the least effective anti-inflammatory treatments in network meta-analyses 3 and causes application-site reactions at rates similar to tacrolimus 3.

Essential Adjunctive Therapy

Moisturizers are strongly recommended for all adults with eczema and should be used regardless of disease activity 1. Apply moisturizers after topical corticosteroids, not before 1.

Treatment Algorithm

For Active Eczema (Flares):

1. Mild disease or facial involvement: Start with mild corticosteroid (hydrocortisone 1%) once daily or pimecrolimus 1% cream twice daily 1
2. Moderate-to-severe disease: Use potent corticosteroid (betamethasone valerate 0.1%, mometasone 0.1%) once daily 1, 2, 3
3. If corticosteroid concerns exist: Use tacrolimus 0.1% ointment twice daily 1
4. Continue treatment until clearance, typically 2-6 weeks 1

For Maintenance (Preventing Flares):

Apply medium-potency corticosteroid to previously affected areas twice weekly (e.g., weekend therapy) 1, 2

Common Pitfalls to Avoid

• Do not use topical corticosteroids continuously without breaks - implement weekend maintenance therapy instead 1, 2
• Do not apply moisturizers before topical medications - this reduces medication efficacy 1
• Do not avoid topical calcineurin inhibitors due to cancer concerns - the absolute risk is very low despite FDA warnings 1, 5
• Do not use very potent corticosteroids as first-line - potent formulations are equally effective with better safety profiles 2, 3
• Avoid topical antihistamines and antimicrobials - these are conditionally recommended against 1

Safety Considerations

Skin thinning with short-term corticosteroid use (median 3 weeks) is rare, with only 36 events among 3,691 participants across 25 trials 3. However, longer-term use (6-60 months) does increase this risk 3. Application-site reactions are most common with tacrolimus and crisaborole, least common with corticosteroids 3.