First steps
First, avoid anything that dries out your skin and ensure your skin is hydrated. Initial treatment for eczema consists of emollients and topical steroids.
Emollients
What is an emollient? An emollient is a substance that forms a film that makes the skin look and feel smooth. Most dermatologists say to find one that contains petrolatum. You can find emollients from the following common brands: Eucerin, Cetaphil, Aquaphor, CeraVe, Lubriderm and Vaseline.
Studies show that leave-on emollients after a bath can help. Adding oils or colloidal oatmeal (e.g. Aveeno, Dr Teal’s, etc.) to your bath, however, does not appear to help for eczema symptoms. Read on.
Low-potency topical steroids
The choice of strength for a topical steroid should be based on how much of your skin is affected and how bad the inflammation is. Steroids help contain excessive inflammation but can come with side effects like skin thinning if they’re too strong or used for too long. For mild eczema, you’ll start with a low-strength steroid ointment, especially for areas at risk for thinning with steroid use like face and skin folds.
Low-strength steroids include desonide 0.05% or hydrocortisone 2.5%. Both are available only by prescription but are cheap. Desonide comes in a 60 g tube and hydrocortisone comes in a large 454 g jar. You may use these one or twice a day for two to four weeks.
Treatments for moderate to severe eczema
Medium- to high-potency topicals
If low-strength steroids don’t work for eczema on your face or skin folds, your next step might be a topical calcineurin inhibitor, which acts on the immune system to reduce inflammation. Popular medications in this class include tacrolimus 0.1% (Protopic) and Elidel 1%, but they can be expensive or require prior authorization from your insurance company.
For moderate eczema rashes in other areas, ratchet it up to medium- and high-strength steroids like fluocinolone 0.025% cream or ointment, triamcinolone 0.1% or betamethasone dipropionate 0.05%.
Phototherapy and immunosuppressant pills
Have moderate to severe eczema that doesn’t respond to topical therapy? Phototherapy or immunosuppressant pills are then used to control eczema symptoms. Cyclosporine, methotrexate, azathioprine and mycophenolate are all options that are tried and true.
How to prevent relapses
For folks with moderate to severe eczema, you’ll want to be proactive with continuous therapy of topical steroids or calcineurin inhibitors. The topical steroids fluocinolone 0.025%, triamcinolone 0.1%, and betamethasone dipropionate 0.05% should be applied once daily two days per week for up to four months for maintenance.
What’s new for eczema?
Dupixent
Dupixent is an expensive injection that blocks pro-inflammatory substances in the body called cytokines. Studies show that Dupixent could be a viable option for severe eczema if the above treatments don’t work. So far, Dupixent’s high cost is limiting its widespread use.
Eucrisa
Eucrisa ointment is another expensive eczema medication. It’s a topical PDE4 inhibitor approved by the FDA in December 2016. Although Eucrisa seems to be generally safe for long-term use, we don’t really know how it compares to topical corticosteroids or calcineurin inhibitors, so for its cost, we aren’t sure if it’s any better…yet.
Dr O.
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