While there’s no total cure for eczema, treatment has come a long way in recent years. With the right plan, you may be able to achieve remission—meaning few if any symptoms—and stay there a while. There are more medications available than ever to help you do just that, but understanding the differences between them can be confusing. Which meds work best for a flare? What if your eczema is mild—or more severe? From topical steroids to biologic drugs, we’ll break down all your medication possibilities, along with benefits, side effects, and more.
What Is Eczema Again?
It's red, it's itchy, and it's a daily battle for 30 million people in the U.S who have been diagnosed with this chronic condition. On a good day, it's merely annoying. On a bad one, your inflamed skin can itch like your body is one big mosquito bite.
So what exactly is it? Here are a few facts:
- It might be caused by genetics.
- It can affect anyone from infants to grandparents.
- Its symptoms don’t always look the same.
- There are seven different varieties.
- There is no cure.
Now that you have the basics, here's what you need to know about treating this chronic condition.
Often, your doc will start you off in treatment with a medication you apply to the surface of the skin in the area of discomfort. While topicals tend to be less potent as drugs, they may also have fewer side effects, since they don’t affect your whole body the way oral medications do. These are some of the options your doc may consider:
If you have mild eczema—meaning you’re dealing with just a few small red, itchy patches on your skin—your best option may be a low-dose topical corticosteroid cream or ointment (the latter is often preferred since it tends to be heavier, and thus more moisturizing). This treatment is usually applied once or twice a day, for two to four weeks.
There are a bunch of different corticosteroid creams your dermatologist or primary care physician can choose from, but two good first line treatments are desonide 0.05% and hydrocortisone 2.5%.
If your eczema is more intense—it’s on multiple parts of your body, very itchy, and affecting your sleep and daily life—you can use a stronger steroid on those areas, such as fluocinolone 0.025%, triamcinolone 0.1%, betamethasone, or dipropionate 0.05%. These can’t be used any longer than two weeks, because they carry side effects such as skin thinning, stretch marks, and skin darkening (for this reason, doctors don’t recommend using them on your face).
These types of treatments tend to work quickly and well, since they reduce inflammation in your skin, helping to relieve itching, redness, and soreness and allowing it to heal. (Top tip: Right after you use your corticosteroid cream, apply moisturizer to your body to help seal in the medication and make it more effective.) A review of 83 randomized trials published in Health Technology Assessment found that most patients who use steroids report relief, compared to people using a placebo.
So how much should you use? Follow this rule: Squeeze enough to fit onto the tip of your index finger, between your fingertip and the first finger crease. This amount can cover an area of your skin the size of two flat adult palms. Usually, over-the-counter hydrocortisone creams won’t be strong enough, though, so you’ll need to see your doctor—either your primary care physician, or your dermatologist—for a prescription.
If you’ve tried steroids for a few weeks and your eczema is still flaring up, or you have eczema on sensitive skin areas such as your eyelids, neck, or face, your M.D. may suggest a topical calcineurin inhibitor (TCI), a nonsteroidal medication that works by blocking the action of calcineurin, an enzyme that activates T-cells in your immune system. Because an overactive immune system is responsible for some of the redness and itchy skin with eczema, inhibiting the activation of T-cells can ease these symptoms.
These second-line treatments are applied twice a day directly to the area of skin affected by eczema. There are two drugs currently available:
- Protopic (tacrolimus ointment) for moderate to severe eczema
- Elidel (pimecrolimus cream) for milder cases
Both drugs are considered to be about as effective as medium-potency corticosteroid creams. A meta-analysis of studies including almost 7,000 patients found that almost half of patients who used tacrolimus found symptoms improved by more than 90%. Meanwhile, pimecrolimus completely cleared up symptoms in about 33% of patients after three weeks—more than three times as effective as a placebo.
Another perk of taking TCIs: They can be used as a preventative treatment if you are prone to flares. Adults who used topical tacrolimus for moderate to severe atopic dermatitis twice a week experienced fewer outbreaks and also reported that it dramatically improved their quality of life, according to one study.
There are a few side effects with the TCIs, including a mild burning or stinging sensation when first applied. In rare cases (less than 1%), people who use pimecrolimus have gone on to develop skin cancer or lymphoma—although there are no studies showing a definite cause-and-effect. Because of this, however, it’s important to only use these drugs on areas of skin directly affected by eczema, and chronic long-term use (months to years) isn’t recommended.
Approved by the U.S. Food and Drug Administration in 2016, Eucrisa (crisaborole) is the only topical PDE4 inhibitor available for mild to moderate eczema. This drug works by blocking the actions of phosphodiesterase 4 (PDE4), an enzyme produced by your immune system that controls the presence of cytokines, or proteins that can trigger eczema-causing inflammation.
A study in the Journal of the American Academy of Dermatology found that almost 33% of people who used PDE4 inhibitors for a month reported improvements in symptoms, almost twice as many as those who used a placebo. It comes as a 2% topical ointment that you apply to your skin twice a day. The medication is considered very safe, and side effects are mild, usually no more than minor skin irritation.
When topicals fail to significantly ease the symptoms of eczema, your next step may be to try an injectable. In 2017, the FDA approved Dupixent (dupilumab), an injectable medication that belongs to a class of drugs known as biologics. This drug works on two proteins known as interleukins—IL-4 and IL-13—that trigger eczema. It prevents these proteins from binding to cell receptors, which in turn stops your immune system from overreacting. More than half of people with moderate or severe eczema who use it for 16 weeks experience at least a 75% improvement in symptoms, according to a recent study.
Experts consider dupilumab something of a game-changer, since before its arrival, there was no option to treat severe eczema other than drugs that suppress the immune system, which can have serious side effects. But although dupilumab is really effective, it’s considered a second line treatment, which means dermatologists only prescribe it if you haven’t responded to any of the other drugs listed above. This is because it’s expensive ($37,000 a year without insurance), involves giving yourself a shot every other week, and can cause side effects like redness around the shot site and, more rarely, pink eye and cold sores.
Unlike topical drugs that can be applied directly to the affected area of skin, oral medications are considered systemic drugs, meaning they enter your bloodstream and travel throughout your entire body as they do their job. They can be powerfully effective, but also come with a host of serious side effects, so tend to be reserved for people with severe cases of eczema. Let’s take a closer look:
As a last resort, your dermatologist may prescribe a potent class of drugs called immunosuppressants. These essentially put the brakes on your immune system, which stops the itch-scratch cycle of eczema and allows your skin to heal. There are three that are commonly used:
Imuran (azathioprine) interferes with the proliferation of certain white blood cells known as lymphocytes, which trigger the inflammation that leads to eczema.
Sandimmune (cyclosporine) was traditionally used in transplant patients to prevent their bodies from rejecting their new organ, but helps with eczema by dampening the immune system response.
Trexall/Rasuvo (methotrexate) is a chemotherapy drug (also available as a tablet) that can be used for autoimmune diseases like rheumatoid arthritis. It works by preventing the cells of your immune system from dividing, thereby reducing your immune response.
These medications are considered “off-label,” which means that they’re not approved by the FDA to specifically treat eczema. They also carry potentially serious side effects like high blood pressure and kidney damage, and they make you more vulnerable to infection. As a result, most dermatologists won’t prescribe them for more than 6 to 12 weeks at a time.
If you have a really bad flare and need to see results quickly (for example, you want it to clear up before a wedding in a few days) your doctor may prescribe an oral corticosteroid like prednisone. These drugs are effective but can't be used long term because of side effects like high blood pressure and high blood sugar, weight gain, and even eye problems like cataracts or glaucoma.
Prednisone is typically prescribed at 40 to 60 mg per day for one week, after which the dose is tapered over the following two to three weeks. You’ll then be transitioned to an immunosuppressant drug like methotrexate for another few weeks to make sure symptoms stay under control.
Drugs to Relieve Itching
It’s one of the most common and aggravating symptoms of eczema, and when your skin itches, you’ll do anything to make it stop. But while over-the-counter antihistamines are sometimes employed to ease this discomfort, there isn’t really any good research to show that they’re effective.
The main benefit they have is some of them, such as Benadryl (diphenhydramine), can make you sleepy, so your scratching is less likely to keep you up at night. Other, OTC non-sedating antihistamines like Zyrtec (cetirizine) and Claritin (loratadine) are no more effective than a placebo, according to a 2019 review of studies.
Choosing Your Medication
So which of these drug options is right for you? A lot will depend on how severe your eczema is, where it is located on your body, and your comfort level with various ways of receiving treatment, from rubbing cream on your skin to giving yourself a shot in the leg.
Talk with your dermatologist about your options, and remember, no decision is irreversible. If you try one medication for several weeks or months and do not experience relief—or can’t tolerate the side effects—there are plenty more medications for you to choose from. Eventually, you and your doc will settle on a successful plan to conquer eczema symptoms once and for all.