When atopic dermatitis (also called eczema) is flaring, one of the first-line treatments is topical steroids to lower skin inflammation and itching.
These steroids come in various strengths, with lower-potency options available over the counter and higher-potency creams as a prescription. But they're not meant to be a long-term solution for the condition, according to Tanya Evans, MD, a dermatologist and the medical director of the skin cancer program at the melanoma clinic at MemorialCare Saddleback Medical Center in Laguna Hills, California.
"Topical steroids usually work well to calm down a flare, but you would likely use them only for two or three weeks," she says. "That's because over time, your skin becomes thinner with steroid use, making it more fragile. This is reversible, but it's better to utilize these steroids briefly and occasionally, and turn to other treatments for managing atopic dermatitis."
In some instances, topical steroids for atopic dermatitis don’t help, even with a high-potency prescription formula. That can happen if you're continually exposed to triggers like dry air, dust mites, food allergies, or stress, Dr. Evans says, or if you need a different type of medication. Knowing your triggers and avoiding them is a crucial step, as well as considering other medication options. Here are the ones you'll likely be discussing with your dermatologist.
If topical steroids aren't working to control your atopic dermatitis over time, another topical tends to be the next step, says Evans. As the term implies, these are prescription medications that are applied to your skin in areas where you're experiencing itching and inflammation.
Calcineurin Inhibitors Approved medications are pimecrolimus cream (Elidel) and tacrolimus ointment (Protopic). These are anti-inflammatories that improve the immune system's response in the skin. They work by blocking calcineurin, a protein that triggers inflammation.
Phosphodiesterase-4 (PDE-4) Inhibitors These medications — crisaborole ointment (Eucrisa) and roflumilast cream (Zoryve) — slow down an overactive immune system by blocking the PDE4 enzyme, which can then reduce itching, swelling, and rashes.
JAK Inhibitors There's another group of enzymes in the body involved in triggering inflammation called Janus kinases. JAK inhibitors break up the chain of chemical signals sent within your immune system. Ruxolitinib (Opzelura) is approved for teenagers and adults.
Aryl Hydrocarbon Receptor Agonists Tapinarof cream (Vtama) works to repair your skin’s natural protective barrier and to block inflammation.
"Prescription topicals may be combined with other treatments, depending on symptoms," says Evans. "That would be determined based on how often you're seeing a flare, and the severity of those symptoms."
Unlike topical medications that affect only your skin, systemic medications work throughout your body, reducing inflammation that can lead to atopic dermatitis flares.
There are several main categories of systemic medications for this condition, and each works on a different target to reduce inflammation.
JAK Inhibitors
In the same way that topical JAK inhibitors block the signals that trigger inflammation on the surface of your skin, oral medications reduce that response throughout your immune system.
Options include abrocitinib (Cibinqo) and upadacitinib (Rinvoq). Baricitinib (Olumiant) may be used off-label, and other drugs are moving toward approval by the U.S. Food and Drug Administration for eczema treatment.
"With JAK inhibitors, you may not get clear skin right away, so it's important to be patient, because it may take several weeks," says Evans. "But the good news is that the itching tends to calm down soon after you start the medication."
Biologics
These
injectable medications target specific parts of your immune system, depending on which medication is used. Options include:
- dupilumab (Dupixent)
- lebrikizumab (Ebglyss)
- nemolizumab (Nemluvio)
- tralokinumab (Adbry)
They all work by blocking a type of chemical messenger, called an interleukin, to prevent it from binding to specific cell surface receptors. This action stops or minimizes part of your immune system’s response to a trigger, resulting in lower inflammation.
Immunosuppressants
Both JAK inhibitors and biologics are fairly new in terms of treatment options, and they're being widely used because they don't suppress the immune system like older medications, says Evans. But those more conventional treatments are still used in some cases when other options aren't controlling atopic dermatitis effectively, and the symptoms are severe.
Those choices are:
- cyclosporine
- methotrexate
- azathioprine
- mycophenolate
Oral corticosteroids like prednisone or prednisolone are generally not recommended, as they provide only temporary relief and can cause serious side effects. But they can be used in certain short-term situations.
"In the past, we only had immune suppressant medications like oral or injectable prednisone and cyclosporine that reduced the immune system," Evans says. "Now we have so many options in terms of topical, oral, and systemic medications, and that's exciting. It means both children and adults can often find a suitable treatment that controls their atopic dermatitis without dampening the entire immune system."
Even if you've been on the same medication for months or years, there may be a point where it's not working well anymore, says
Jessica Hui, MD, a pediatric allergist and immunologist at National Jewish Health in Denver. If you've been using topical steroids and they don't seem to be helping, make an appointment with your dermatologist. Signs it’s time for a change include:
- Intense or constant itching
- Fluid-filled bumps or crusting
- Swelling
- Difficulty sleeping due to symptoms
- Increased sensitivity of the skin
- More areas of skin affected
- Fever
- Warmth around affected areas
"We approach eczema treatment in a step-wise way," says Dr. Hui. "That means we can step up therapy and step down therapy, depending on how well the eczema is being controlled. We usually start with the lowest potency of a medication, as well as lifestyle changes, and then consider other types of medications if necessary."
