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

From the Guidelines

Eczema can be effectively managed with a combination of topical corticosteroids, moisturizers, and other targeted treatments, with dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib being strongly recommended for severe cases 1. For mild to moderate eczema, start with a low to medium potency topical corticosteroid like hydrocortisone 1% or triamcinolone 0.1% cream, applying a thin layer to affected areas twice daily for 1-2 weeks. Always follow with a thick moisturizer like CeraVe, Vanicream, or Eucerin applied liberally at least twice daily, even when symptoms improve. Some key points to consider when managing eczema include:

• Using gentle, fragrance-free products for bathing and laundry
• Avoiding triggers like harsh soaps, hot water, and known allergens
• Considering oral antihistamines such as cetirizine 10mg daily to manage itching, especially at night
• Using non-steroidal options like topical calcineurin inhibitors (tacrolimus, pimecrolimus) for sensitive areas like the face
• Considering systemic treatments like oral prednisone, dupilumab injections, or phototherapy for severe or widespread eczema under medical supervision, as recommended by recent guidelines 1. 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

ELIDEL Cream is a prescription medicine used on the skin (topical) to treat eczema (atopic dermatitis). ELIDEL Cream is for adults and children age 2 years and older who do not have a weakened immune system. The medication for eczema is pimecrolimus (TOP), also known as ELIDEL Cream, which is a topical calcineurin inhibitor.

• It is used to treat mild to moderate atopic dermatitis in adults and children aged 2 years and older.
• The cream should be applied twice a day to the affected skin areas, as directed by a doctor.
• Treatment should be for short periods, with breaks in between if needed.
• Patients should stop using the cream when symptoms of eczema go away, or as directed by their doctor 2, 2.

From the Research

Medication for Eczema

• Topical corticosteroids (TCS) are a mainstay of treatment for eczema, with potent and moderate TCS being more effective than mild TCS 3
• The effectiveness of TCS can be influenced by the frequency of application, with once daily application being as effective as twice daily application for potent TCS 3
• Topical calcineurin inhibitors (TCI) are an alternative to TCS, with tacrolimus being more effective than weak TCS in some studies 4
• TCI can be particularly useful for treating eczema on thin or intertriginous skin regions, where TCS may be more likely to cause adverse events 4
• A network meta-analysis found that potent TCS, JAK inhibitors, and tacrolimus 0.1% were consistently ranked as amongst the most effective topical anti-inflammatory treatments for eczema, while PDE-4 inhibitors were ranked as amongst the least effective 5
• Local adverse effects, such as application-site reactions and skin thinning, can occur with both TCS and TCI, but the risk is generally lower with TCS 5

Types of Medication

• Topical corticosteroids:
  • Potent TCS: effective for moderate to severe eczema, but may have a higher risk of adverse effects 3
  • Moderate TCS: effective for mild to moderate eczema, with a lower risk of adverse effects than potent TCS 3
  • Mild TCS: less effective than potent and moderate TCS, but may be suitable for mild eczema or for use on sensitive skin areas 3
• Topical calcineurin inhibitors:
  • Tacrolimus: effective for moderate to severe eczema, particularly on thin or intertriginous skin regions 4
  • Pimecrolimus: less effective than tacrolimus, but may be suitable for mild eczema or for use on sensitive skin areas 4

Treatment Strategies

• Proactive treatment with topical corticosteroids or TCI can help prevent eczema flare-ups and improve long-term control of the disease 3
• Reactive treatment, where medication is only applied during flare-ups, may not be as effective as proactive treatment in preventing future flare-ups 3
• Combination therapy, where multiple medications are used together, may be effective for some patients with eczema, but more research is needed to determine the best combination regimens 5