What are the treatment options for atopic dermatitis (eczema)?

From the Guidelines

Eczema treatment should prioritize a combination of moisturizing, topical medications, and trigger avoidance, with consideration of phototherapy and systemic therapies for more severe or refractory cases, as recommended by the most recent guidelines from the American Academy of Dermatology 1. For mild to moderate eczema, the following approaches are recommended:

• Regular application of fragrance-free moisturizers like CeraVe, Eucerin, or Vanicream at least twice daily, especially after bathing while skin is still damp
• Topical corticosteroids as the first-line medication treatment, with options ranging from over-the-counter hydrocortisone 1% for mild cases to prescription-strength formulations like triamcinolone 0.1% or fluocinonide 0.05% for more severe flares
• Apply a thin layer to affected areas 1-2 times daily for 1-2 weeks during flares
• For maintenance or sensitive areas like the face, non-steroidal alternatives such as tacrolimus (Protopic) or pimecrolimus (Elidel) can be used
• Antihistamines like diphenhydramine or cetirizine may help reduce itching, particularly at night
• Avoid known triggers including harsh soaps, fragrances, certain fabrics like wool, stress, and extreme temperatures
• Take short, lukewarm showers rather than hot baths, and use gentle, fragrance-free cleansers For more severe or refractory cases, phototherapy and systemic therapies may be considered, including:
• Ultraviolet B, ultraviolet A1, and psoralen plus ultraviolet A phototherapy
• Injectable monoclonal antibodies (biologics) such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib
• Oral Janus kinase inhibitors
• Older oral immunomodulators and oral or injectable antimetabolites, such as azathioprine, cyclosporine, methotrexate, and mycophenolate The decision to initiate these more advanced therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of eczema, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.

From the FDA Drug Label

Uses temporarily relieves itching associated with minor skin irritations, inflammation, and rashes due to: eczema Directions for itching of skin irritation, inflammation, and rashes: adults and children 2 years of age and older: apply to affected area not more than 3 to 4 times daily Eczema treatment with hydrocortisone (TOP) involves applying the product to the affected area not more than 3 to 4 times daily for adults and children 2 years of age and older 2 2.

• For children under 2 years of age, a doctor should be consulted before use.
• It is used to temporarily relieve itching associated with eczema.

From the Research

Eczema Treatment Options

• Topical corticosteroids are a first-line treatment for eczema, with potent and moderate topical corticosteroids being more effective than mild topical corticosteroids, primarily in moderate or severe eczema 3
• The effectiveness of topical corticosteroids is similar between once daily and twice daily (or more) frequent use to treat eczema flare-ups 3
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 3
• Potent topical steroids, Janus kinase inhibitors, and tacrolimus 0.1% are consistently ranked as among the most effective topical anti-inflammatory treatments for eczema 4
• Maintenance therapy for eczema consists of liberal use of emollients and daily bathing with soap-free cleansers, with topical corticosteroids being the first-line treatment for atopic dermatitis flare-ups 5
• Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment for atopic dermatitis 5, 6
• Newer medications, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost-prohibitive for most patients 5

Adverse Events

• Local adverse events, such as abnormal skin thinning, are not well reported and come largely from low- or very low-certainty, short-term trials 3
• Skin thinning was not increased with short-term use of any topical steroid potency, but skin thinning was reported in 6/2044 (0.3%) participants treated with longer-term (6-60 months) topical steroids 4
• Local application site reactions were most common with tacrolimus 0.1% and crisaborole 2%, and least common with topical steroids 4

Treatment Duration and Frequency

• There is a need for longer-term trials to determine the optimum duration of treatment for eczema flare-ups 3
• The frequency of topical corticosteroid application, such as once daily or twice daily, does not appear to affect treatment success 3
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 3