top of page

How is eczema (atopic dermatitis) treated in adults and children?

Updated: May 19, 2023



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

What is eczema?


Eczema, also known as atopic dermatitis, is a chronic inflammation skin condition. It occurs most frequently in children, but also affect many adults.


People with eczema experience skin dryness and itching. A person with eczema often breaks out in red, dry, itching and scaly patches on their skin.


Sometimes, the skin can be crusted and oozing as a result of scratching or a bacterial infection.


Other times, the skin can be thickened as a result of frequent itching and scratching.


There may be episodes of severe itching and rash that last for weeks or months.


Eczema tends to affect the eyelids, neck, front of the elbows, back of the knees, ankles, palms of the hands and soles of the feet in adults.


In infants, eczema tends the affect the face, and can sometimes affect the whole body.


In children and adolescents, it starts to gradually taken on the more adult pattern of skin involvement.



How severe is your eczema?


How eczema is treated depends largely on how severe it is.


The severity of eczema is generally broken down into three levels – mild, moderate and severe.


In mild eczema, a person typically experiences dry skin, and infrequent itching. There may be small patches of redness.


In moderate eczema, a person regularly experiences itching, and frequently breaks out multiple patches of red, itching and scaly rash.


In severe eczema, a person experiences continuous itching. Large patches of skin are also broken out in a red, itching and scaly rash. There is also oozing and bleeding and skin thickening from scratching. In addition, eczema is also limiting daily social and other functional activities.



What causes eczema?


There are several factors that play a role in eczema.


Firstly, many people who develop eczema have a genetic predisposition for it. That means they may have inherited genes that increase the chance of having eczema. This explains why eczema often runs in families.


The skin barrier in people in eczema is disrupted. It appears that the skin in eczema is not able to maintain a normal barrier and maintain hydration. This leads to increased loss of water from the skin even when a person drinks an adequate amount of water.


This causes the skin to be dry and itching.


In addition, there is an increase immune system sensitivity (termed type 2 immune response) observe in people with eczema.


This means that the immune system has a increased ability to react to various triggers both within and outside the body.


This complex increased immune response causes skin redness, itching, hypersensitivity and inflammation.



What makes eczema worse?


There are different lifestyle and environmental triggers that can make eczema worse.


Some of the common ones are:

  • Excessive bathing without moisturizing the skin

  • Low humidity environments

  • Emotional stress

  • Skin care products and detergents that contain fragrances or irritates the skin

  • Excessive heat

  • Bacterial skin infections by Staph aureus (also known as impetigo)



Treatment of dry skin


The key to treating eczema is reducing dry skin and maintain skin hydration.


There are a large variety of moisturizing products available that helps maintain skin hydration.


It is recommended for moisturizers to be applied at least twice a day, and after taking a shower or bath.


The best time to apply a moisturizer is immediately after a bath or shower when the skin is well hydrated.


In fact, one of the most effective way to hydrate the skin and relieve itching is to taken a short mildly warm bath followed immediately by applying a moisturizer.


Maintaining skin hydration must be a continuous daily routine for people with eczema regardless of other treatments used because it reduces the severity and frequency of flare ups.



Types of moisturizers


Moisturizing products can be divided into lotions, creams and ointments.


Lotions have high water content and low oil content. This means lotions evaporate fairly quickly, and may not maintain skin hydration effectively.


Creams have a higher oil content and lower water content, and coats and maintains skin hydration more effectively than lotions.


Ointments, on the other hand, are oil based, and have minimal water content. They are highly effective in reducing dry skin and maintaining skin hydration, but they feel greasy.


There are also moisturizing products that contain ceramide. Ceramide a lipid that is found on healthy skin, and plays a role in maintaining skin hydration. Ceramide is found to be deficient in the skin of people with eczema. As such, using moisturizers that contain ceramide is thought to be beneficial in reducing dry skin in eczema.



Topical treatments for mild to moderate eczema


There are several topical treatments available for eczema.


These topical treatments are broadly categorized into corticosteroids-based and non-steroid based treatments.



Topical corticosteroids (steroids)


The use of topical steroids combined with regular use of a moisturizer is the main treatment for most people with eczema.


Many people have misconceptions of what corticosteroids are.


Corticosteroids are naturally produced within our body as a hormone called cortisol.


Topical steroids are cortisol-based treatments that reduce inflammation when applied directly on the skin.


Topical steroids do not cure eczema. They simply treat the symptoms by reducing inflammation, redness and itching.


These are typically applied to the eczema affected areas once to twice a day for two to four weeks, then as needed after that when a person’s skin is broken out.


Topical steroids are available as a wide variety of ingredients, each with a different strength and concentration, ranging from mild to very strong (ultrapotent).


Naturally, the strong the steroid ingredient, and the higher the concentration, the more effective it is.


Some examples of mild topical steroids are hydrocortisone and desonide.


Hydrocortisone 1% cream is sold over-the-counter in the United States, and is available at 2.5% strength as a prescription.


Commonly prescribed medium strength topical steroids include triamcinolone and mometasone.


The stronger topical steroids are clobetasol, halobetasol and betamethasone diproprionate.


Topical steroids also come in a variety of vehicles including solutions, lotions, creams, gels and ointments. A thicker, oil-based vehicle, like an ointment, increases the effectiveness of the active ingredient compared to a water-based vehicle like a lotion.


Potential side effects of topical steroid use


Long term use of topical steroids can cause skin thinning, stretch marks, visible blood vessels (called telangiectasia) and localized increased hair growth.


Excessive use of topical steroids over the eyelids can increase the risk of cataracts and glaucoma.


Using medium and strong topical steroids on the face can also cause acne or rosacea to break out.


Hence, it is important to follow the directions given by your dermatologist on where to apply the topical steroid you are prescribed.


The internal side effects associated with oral steroid use are rarely reported from topical steroid use unless large quantities are used over the long term.


If large quantities of topical steroids are used on large body areas for the long term, then it may lead to suppression of the body’s own ability to produce steroid hormones (also known as adrenal suppression).



Non-steroid based topical treatments


There are currently three non-steroid based topical treatments for eczema:

  • Topical tacrolimus (Protopic®)

  • Topical pimecrolimus (Elidel®)

  • Topical cisaborole (Eucrisa®)

  • Topical ruxolitinib (Opzelura®)



Topical tacrolimus (Protopic®) and topical pimecrolimus (Elidel®)


Both topical tacrolimus and pimecrolimus belong to the same class of medication called calcineurin inhibitors.


They both work by decreasing inflammation and itching in eczema.[1]


Tacrolimus comes in two strengths 0.1% and a milder 0.03%, whereas pimecrolimus comes in a single strength.


Like topical steroids, both tacrolimus and pimecrolimus help eczema by reducing inflammation, redness and itching. They do not cure eczema.


They are considered to be about similar in strength to medium-strength topical steroids.


These treatments are applied once to twice a day as needed to the skin affected by eczema.


The benefit of topical tacrolimus and pimecrolimus, compared to topical steroid, is they do not cause skin thinning.


Hence, these treatments can be applied to almost every part of the skin that is affected by eczema, especially the face, neck and areas where the skin is naturally thin.


In the United States, these treatments are approved by the FDA for use in adults and children over 2 years of age.


Most people tolerate these treatments well without side effects.


The most common side effect of topical tacrolimus is a burning sensation around where the treatment is applied, and usually goes away after a few days of starting treatment.


Some people may experience facial acne or rosacea, and reactivation of herpes simplex, when applying these treatments.


Long term use of ORAL tacrolimus, is known to increase the risk of cancer including lymphoma.


In the United States, there is a FDA Black Box warning on topical tacrolimus to ensure patients are aware of this concern.


The risk of lymphoma and the use of topical tacrolimus and pimecrolimus was studied in a large analysis which concluded that “there is a slight increased risk of lymphoma in people with atopic dermatitis” and “the role of topical steroids and topical calcineurin inhibitors is unlikely to be significant”.[2]



Topical crisaborole (Eucrisa®)


Topical crisaborole, better known as Eucrisa in the United States, is a relatively new topical treatment for eczema.[3]


It is not a topical steroid.


It is a boron-based treatment. Boron is a trace mineral found in food, such as nuts, and the environment.


It reduces inflammation by blocking a part of the immune system called PDE4, which reduces itching and redness in the skin.


It is FDA approved in 2016 for treating eczema in adults and children older than 2 years of age.


It is an ointment-based product and is meant to be applied twice a day to areas of skin affected by eczema.


The most common side effect of crisaborole is a burning or stinging sensation around the area where the treatment is applied.



Topical ruxolitinib (Opzelura®)


Topical ruxolitinib (Opzelura®) is a eczema treatment that belongs to a group of medications called JAK inhibitors.


Inflammation in eczema is caused in part by increased activity along an immune system pathway called the JAK pathway.


Topical ruxolitinib blocks the JAK pathway in the immune system and reduces itching, inflammation and skin redness.


It is FDA-approved to treat adults and children older than 12 years of age with mild to moderate eczema.


Ruxolitinib is applied directly to affected areas of skin twice a day for up to 8 weeks.


Some reported side effects include runny nose, ear infection, inflammation of the nasal passage and tonsils.


There is an FDA warning for serious side effects with ORAL JAK inhibitors that include the risk serious infection, heart disease, blood clots (thrombosis) and cancers.


The topical formulation of ruxolitinib was developed to deliver the treatment directly to the skin and limit the potential of these severe side effects.



Phototherapy treatment for moderate and severe eczema


Phototherapy involves using ultraviolet (UV) B light to treat eczema, specifically narrowband UVB.[4]


Phototherapy with UVA1 is also available in certain dermatology centers, however narrowband UVB is the most common phototherapy available.


Phototherapy with narrowband UVB is able to decrease both itching and inflammation.


It is usually used when eczema is not controlled by topical treatment alone.


The treatment involves a person standing in a light box with bulbs that emit.


The treatment is usually administered two to three times a week, and lasts a few minutes each time.


While undergoing phototherapy, topical treatments may still be used if needed.


While phototherapy is not associated with internal side effects, prolonged use of phototherapy may lead to an increased risk of developing skin cancers including melanoma.


Phototherapy may also increase skin dryness after a treatment session, and topical moisturizer use is recommended.



Systemic (Internal) treatments for moderate to severe eczema


There are a few oral and injectable treatments for people with moderate to severe eczema.


These include:

  • Dupilumab (Dupixent®)

  • Tralokinumab (Adbry®)

  • Abrocitinib (Cibinqo®) and Upadacitinib (Rinvoq®)

  • Cyclosporin

  • Methotrexate

  • Prednisone


They all work by suppressing a part of a person’s immune system, which reduces inflammation.


As you can imagine, these treatments would also be associated with internal side effects.



Dupilumab (Dupixent®)


Dupilumab is a relatively new treatment for people with moderate to severe eczema.[5]


It is usually used with eczema is not controlled with topical treatments or phototherapy, or other oral medications.


Dupilumab is a human antibody that blocks a part of the immune system (called the Th2 pathway) that plays a key role in eczema as well as asthma.


It is an injectable treatment that is self-administered every 2 weeks.


In clinical trials, dupilumab resulted in 75% decrease in severity of eczema in about 50% of patients.


It is one of the most effective treatments for moderate to severe eczema currently available.


Dupilumab is FDA approved for use in adults and children aged 6 years and older with moderate to severe eczema.


The most common side effects reported are a skin reaction at the injection site and conjunctivitis (redness of the eyes).


Some people who used dupilumab reported an increase in facial redness, of which the cause is not clear.


The risk of infections with dupilumab appears to be low.



Tralokinumab (Adbry®)


Tralokinumab is a human antibody that blocks a part of the immune system (called interleukin-13).


It is used to treat eczema that is not controlled with topical treatments.


It is an injectable treatment that is self-administered every 2 weeks.


In clinical trials, tralokinumab resulted in 75% decrease in severity of eczema in about 30% to 55% of patients after 4 months of treatment.


Tralokinumab is FDA approved for use in adult age 18 years and older.


The most common side effects are common cold, conjunctivitis and injection site reactions.



JAK inhibitors - Abrocitinib (Cibinqo®) and Upadacitinib (Rinvoq®)


Abrocitinib and Upadacitinib are oral medications that block the JAK pathway in the immune system, and in doing so, reduces inflammation in eczema.


While both medications are used to treat eczema, Abrocitinib (Cibinqo®) is FDA approved for adults only, and upadacitinib (Rinvoq) is FDA approved for adults and adolescents aged 12 and older.


Both treatment are taken by mouth once a day.


In clinical trials, these medications resulted in 75% decrease in severity of eczema in 40% to 80% of patients.


Both medications carry warnings of potential serious side effects including increased risk of developing serious infections, heart disease, blood clots (thrombosis) and cancers.


As a result, these oral medications are mainly used to treat patients with severe eczema when other treatments have not worked.


Cyclosporin


Cyclosporin[6] an oral medication is often used as a short-term rescue treatment for people with moderate to severe eczema.


It leads to rapid decrease in inflammation usually within 1 month.


Cyclosporin works by broadly suppressing a person’s immune system. This means there is an increased risk of developing infections, including serious infections when taking cyclosporin.


In addition, cyclosporin increases the risk of kidney toxicity, high blood pressure, increased hair growth and gum swelling.


As such, people who take cyclosporin will have their kidney function and blood pressure monitored regularly.


Cyclosporin is prescribed as a daily medication taken twice to three times a day depending on a person’s body weight.



Methotrexate


Methotrexate[7] has been used for long term control of moderate to severe eczema that does not respond to other topical treatments or phototherapy.


It also broadly suppresses a person’s immune system, which reduces the inflammation in eczema.


It is an oral medication that is taken once a week in combination with daily supplement of folic acid. Folic acid reduces the risk of developing side effects from methotrexate.


Methotrexate takes time to work. It may take one to two months to notice the improvement in eczema.


The common side effects of methotrexate are stomach upset, headache and feeling tired (fatigue).


Methotrexate can also cause liver toxicity and suppression of a person’s bone marrow function (which produces blood cells).


As such, people taking methotrexate require lab testing to monitor blood counts and liver function.


Methotrexate can cause severe birth defects if used during pregnancy and should not be used during pregnancy. For safety, it is recommended that methotrexate be discontinued 3 months prior to trying to get pregnant in both men and women.



Prednisone


Prednisone is an oral form of corticosteroid (steroid).


It is usually used for short term treatment for rapid relief of eczema, especially during a flare up.


It also reduces inflammation by suppressing the immune system broadly.


It not recommended for long term use to control eczema because of a long list of potential internal side effects associated with long term use.


These include the increased risk of severe infections, cataracts and glaucoma, high blood pressure, high blood sugar (diabetes), weakened bones (osteoporosis) and muscle weakness.


Long term use of oral steroid also suppresses the body’s ability to make its own steroid hormones (adrenal suppression).




I hope you found this information on eczema, and its various treatment options helpful. I hope it will aid you when you make your medical decisions with your dermatologist.


[1] Ashcroft DM et al. Efficacy and tolerability of topical pimecrolimus and tacrolimus in the treatment of atopic dermatitis: meta-analysis of randomised controlled trials. BMJ. 2005;330(7490):516. Epub 2005 Feb 24. [2] Legendre L et al. Risk of lymphoma in patients with atopic dermatitis and the role of topical treatment: A systematic review and meta-analysis. J Am Acad Dermatol. 2015;72(6):992. [3] Paller AS et al. Efficacy and safety of crisaborole ointment, a novel, nonsteroidal phosphodiesterase 4 (PDE4) inhibitor for the topical treatment of atopic dermatitis (AD) in children and adults. J Am Acad Dermatol. 2016;75(3):494. Epub 2016 Jul 11. [4] Sidbury R et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327. [5] Simpson EL et al. SOLO 1 and SOLO 2 Investigators. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. N Engl J Med. 2016;375(24):2335. [6] Roekevisch E, Spuls PI, Kuester D, Limpens J, Schmitt J. Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: a systematic review. J Allergy Clin Immunol. 2014;133(2):429. [7] Goujon C et al. Methotrexate Versus Cyclosporine in Adults with Moderate-to-Severe Atopic Dermatitis: A Phase III Randomized Noninferiority Trial. J Allergy Clin Immunol Pract. 2018;6(2):562.

Recent Posts

See All

Comments


bottom of page