Which Medications Can Help Severe Eczema?
Judi Ebbert, PhD, MPH, RN | Sept 13, 2017
Reviewed by Michael Lehrer, MD on Dec 10, 2017
Can eczema be cured?
Eczema can be managed but not cured. About 15 million people in the U.S. have severe eczema, or atopic dermatitis. Its exact cause is unknown, but experts believe it is a blend of genetic, immune and environmental factors. Physical signs and symptoms are burdensome. Constant itching compromises sleep. The rash, although not contagious, causes stigma, contributing to depression and anxiety. Dermatologic experts agree that finding more effective treatment is a public health priority.
Are there medication guidelines for severe eczema?
In a word, yes. The American Academy of Dermatology has published guidelines for topical therapies, which are applied directly to the skin. The AAD makes strong recommendations for using three types of topical therapies: moisturizers, corticosteroids, and calcineurin inhibitors. In this slideshow we’ll discuss recommended treatment approaches for topical therapies and systemic agents, as well as promising new therapies that are currently being tested.
Why is daily moisturizing essential?
Moisturizing prevents the dryness that promotes eczema flare-ups. The most effective moisturizer is an emollient with petroleum jelly, applied immediately after bathing and swimming. The oil content in an emollient is much higher than the amount found in runny lotions. The oil in an emollient protects the skin by holding in moisture — the greater the amount of oil, the greater the protection.
Why rely on a doctor's guidance when using hydrocortisone?
Hydrocortisone creams reduce itching and inflammation, and they are available in various strengths. During a flare-up, once-daily application works for many, while others need to apply the cream twice a day for relief. To maintain relief, the American Academy of Dermatology recommends using hydrocortisone cream one to two times a week to areas prone to flare-ups. Dermatologists know the potency of hydrocortisone and can recommend the best strength for optimal relief.
Is hydrocortisone risky?
With continuous long-term use, hydrocortisone can have side effects. Associated risk is low, but it’s important to know that prolonged use of potent hydrocortisone can suppress the interactive function of the hypothalmus, pituitary, and adrenal glands. High levels of hydrocortisone can also thin the skin. That’s why it’s wise to have periodic exams at intervals recommended by your doctor. Monitored use of hydrocortisone is the best way to prevent side effects.
What are topical calcineurin inhibitors (TCIs)?
TCIs are another class of anti-inflammatory drugs that the AAD strongly recommends. TCIs block mediators of inflammation. Two TCIs are used for eczema: tacrolimus ointment and pimecrolimus cream. The AAD recommends twice daily application for a flare-up, with twice weekly use during remission. Side effects are rare, with occasional stinging. Long-term safety has not yet been studied. TCIs can help break up the continuous use of hydrocortisone. Sometimes the two are used together.
Do antihistamines help?
The AAD asserts that although people with eczema have tried them, antihistamines have not been helpful and are not recommended. The only observed positive response was short-term relief of itching with the use of doxepin, but no reduction or control of severity. Their use is not recommended because of risk of absorption, a toxic effect caused by too much of the substance entering the skin, and risk of contact dermatitis.
Are there new topical agents?
A phosphodiesterase inhibitor is an anti-inflammatory drug that did well in clinical trials being conducted when the AAD published its guidelines. According to a 2016 FDA press release, safety and efficacy were established in two placebo-controlled studies of people with mild to moderate atopic dermatitis. Participants achieved a greater response with clear or almost clear skin after 28 days of treatment.
Are there other resources on medications?
A board-certified primary care physician or dermatologist is always the best source of information. The National Eczema Association (NEA) provides a backup resource. NEA’s product testing program lists remedies whose effectiveness has earned the NEA Seal of Acceptance™. While not all manufacturers request NEA testing, NEA-tested products can be found at this link.
First-line systemic drug: Cyclosporin A
When severity persists despite use of topical agents, a systemic treatment may be prescribed. Systemic treatment refers to medicine that is swallowed or infused, then travels in the bloodstream to cells throughout the body. A team of experts assessed the strength of systemic agents based on efficacy and safety for 12 agents. They found sufficient evidence to support just one. Cyclosporin A is recommended as first-line treatment for short-term use.
Second- and third-line systemic drugs: Azathioprine and Methotrexate
A second-line treatment option is azathioprine, but evidence is weaker than for Cyclosporin A. Methotrexate can be considered as a third-line option. The lack of supportive evidence does not mean the drugs are ineffective. More data from randomized controlled trials is needed to make a strong recommendation.
Other systemic drugs
The team did not find sufficient evidence to make recommendations for mycophenolate, montelukast, intravenous immunoglobulins, and systemic glucocorticosteroids. The team’s inability to find data, again, does not mean the drugs are ineffective. It means that not enough studies have been done to confirm efficacy and safety. If a doctor recommends one of the preceding drugs, it’s wise to try the drug and discontinue it if it is ineffective or causes side effects.
Emerging systemic therapies
For several years, clinical scientists have been looking at biologic agents. The FDA defines biologics as proteins, blood products, vaccines, cellular therapies and more. Biologics for eczema aim to improve skin barrier function, reduce sensitivity to allergens, and target and modulate individuals’ immune responses. Unlike traditional systemic therapies, targeted biologics hold promise for low toxicity, good efficacy, less frequent dosing, better control of eczema, and fewer relapses.
An emerging targeted therapy, dupilumab, showed significant improvement in patients with moderate to severe eczema. This has now been FDA approved and may be a promising new way to treat patients with difficult to control eczema.
Medication Management Tip: Track results
Experts acknowledge the need for intensified research on the management of eczema. Research on targeted therapies is in progress. Newer therapies will be accessible in clinical trials. For every medication you take, track how long it takes to get relief — and how long relief lasts. That way, the next time you take the medication, you can gauge its effectiveness. If it doesn’t work as well, consult your doctor about an alternative therapy.