Medications and Other Therapies Used to Treat Eczema

Topical (applied to the surface of the skin) medications play an integral role in controlling the signs and symptoms of eczema, and moisturizer is an essential part of most treatment plans. Systemic medication (medication that circulates throughout the body and is taken orally or given by injection or infusion) also may be prescribed.

Dermatologists use medication and other therapies to:

• Control itching
• Reduce skin inflammation
• Clear infection
• Loosen and remove scaly lesions
• Reduce formation of new lesions

A patient (or parent) may be instructed to use one medication or a combination of therapies. Research is showing that combination therapy (use of two or more therapeutic agents) can in some cases increase effectiveness and reduce side effects. Medications and other therapies that dermatologists may use to treat eczema include: 

MEDICATIONS
Antibiotics
Skin affected by eczema frequently becomes infected.  A topical or systemic antibiotic may be prescribed to clear the infection.

Research demonstrates
that an oral antibiotic can
be highly beneficial when
the skin becomes infected
or a secondary infection develops. Oral antibiotics
are frequently prescribed when a patient has atopic dermatitis because individuals with this condition often have Staphylococcus aureus, a bacterium that causes “staph” infections, colonizing their skin. This bacterium is frequently the cause of secondary infection. Oral antibiotics should be taken exactly as prescribed.

What it does: Kills bacteria causing the infection.

Usage: This depends on the antibiotic prescribed and severity of the infection. It is especially important to use antibiotics as prescribed. Patients should not skip doses nor stop using the medication as soon as they feel better. Doing so may allow some of the bacteria to remain and possibly become resistant to the medication.

Antihistamines
When itching is severe, antihistamines may be prescribed. While there is little scientific evidence that either sedating or non-sedating antihistamines are effective in relieving itch and other symptoms, sedating antihistamines can be useful for patients experiencing significant sleep disruption due to a constant, unbearable itch and other symptoms. It is believed that the improvements associated with antihistamine use are due primarily to the patient getting a restful sleep.

What it does: These pills do not clear eczema. However, sedative antihistamines may promote a restful sleep, and this restful sleep is believed to decrease the severity and improve the patient’s quality of life.

Usage: This depends on the antihistamine and severity of the eczema. Antihistamines should be taken exactly as prescribed. While research shows that antihistamines are safe and not associated with significant adverse effects, even in very young patients when taken as prescribed, taking a higher dose than prescribed can be dangerous, especially for young children.

Calcineurin Inhibitors
Pimecrolimus and tacrolimus belong to a class of drugs called calcineurin inhibitors, which effectively reduce the inflammation of atopic dermatitis. Available in topical form by prescription, these two steroid-free medications are the newest treatment option for atopic dermatitis and a much-welcomed addition because they do not produce the side effects, such as thinning skin and loss of effectiveness, associated with long-term use of topical corticosteroids. As such, calcineurin inhibitors can be used for longer periods.

Currently, pimecrolimus and tacrolimus are FDA-approved for treating atopic dermatitis in patients who are two years of age or older and cannot use or have not responded to other treatments for eczema. Both medications can be used for short-term and intermittent long-term treatment. Tacrolimus received FDA approval for the treatment of moderate to severe atopic dermatitis in December 2000. Pimecrolimus received approval in December 2001 for treating mild to moderate atopic dermatitis.

In clinical trials, side effects were mild and temporary. Some patients using pimecrolimus experienced a mild to moderate temporary sensation of warmth or burning at the application site, headache or cold-like symptoms. When applying tacrolimus, some patients also experienced stinging and burning upon application. The more severe the eczema, the more likely the patient was to experience these side effects. The burning sensation was usually confined to the area being treated and tended to subside after the first week.

What it does: Topical calcineurin inhibitors (TCIs) reduce inflammation. Scientists believe that these medications work by selectively modifying or suppressing the over-response that occurs in the immune system, which causes the inflammation.

Usage: The recommended dosage for both pimecrolimus and tacrolimus is to apply a thin layer twice a day to the affected area(s) until the skin clears.

Who should not use: Neither medication should be used by a patient with a weakened immune system.

Avoid sunlight and other UV exposure: Patients should avoid exposure to sunlight, tanning beds, sun lamps and treatment with ultraviolet (UV) light while taking these medications. Sun protection is essential. Be sure to avoid the midday (between 10 a.m. and 4 p.m.) sun. Even when going outdoors for a few minutes sun-protection practices must be followed. Wear loose-fitting clothing that protects the treated area from sunlight, apply a sunscreen with an SPF of 15 or higher to all exposed skin 20 minutes before going outdoors, use a sunscreen for the lips that has an SPF of at least 15, and wear a wide-brimmed hat and sunglasses.

Pregnancy: Women who are pregnant, breast-feeding or may become pregnant should discuss safety with their dermatologist. Research shows that the oral form of tacrolimus crosses the placenta and appears in breast milk, making it inappropriate for use by pregnant or breast-feeding women.

Coal Tar
Coal tar has a soothing effect on inflamed skin and has been used for many years to treat atopic dermatitis. Today, coal tar comes in numerous preparations, and some of these are available over-the-counter. Best results are typically seen when use is supervised by a dermatologist. While effective and free of serious side effects, patients often prefer other treatment options because coal tar has an unpleasant odor and stains just about everything it touches.

What it does: Reduces inflammation and itching.

Usage: Coal tar preparations are available in many forms, including lotion, shampoo and a preparation that can be added to the bath. All forms should be used as directed by a dermatologist.

Corticosteroids
Available both over-the-counter and by prescription, topical corticosteroids have been used since the 1950s to treat eczema. Today, dermatologists use topical corticosteroids more than any other medication to alleviate the signs and symptoms of eczema. Also known as glucocorticoids and steroids, corticosteroids come in a variety of strengths, ranging from mild to extremely potent. The strength prescribed depends on the patient’s age and medical history, severity of the eczema, where on the body the medication will be used and the size of the area(s) to be treated. While many patients have concerns about using corticosteroids due to potential side effects, the likelihood of a side effect occurring is rare when corticosteroids are used as prescribed. Side effects, such as thinning skin, dilated blood vessels, stretch marks and loss of effectiveness, tend to occur when high-potency corticosteroids are used over long periods of time.

In severe cases, intramuscular injections of a corticosteroid or short-term therapy with a corticosteroid in pill or liquid form may be prescribed to provide relief from chronic itching. These therapies also may be used to prevent major exacerbations of atopic dermatitis. However, systemic corticosteroids are used sparingly in adults and rarely in children due to the possibility of:

• Potential side effects
• Diminished effectiveness with use
• Rebound flare-ups that may occur when the medication is stopped

Systemic treatment is not recommended for long-term use. Fortunately, significant improvement is usually seen within a few weeks, and the remaining signs and symptoms can be successfully treated with topical agents and lifestyle modifications.

What it does: Corticosteroids tend to rapidly and effectively reduce inflammation, which relieves itching.

Usage: Topical corticosteroids are applied in a thin layer to the skin as prescribed and used for limited periods of time. To prevent potential side effects, care should be taken when applying this medication around the eye, to skin that is diapered or bandaged and to body folds.

Systemic corticosteroids may be prescribed in a pill or liquid form or given as an injection.

Pregnancy: Pregnant and breast-feeding women should not take systemic corticosteroids because these medications cross the placenta. Children who may have been exposed to systemic corticosteroids before birth (or while being breast-fed) should be monitored for suppression of adrenal and pituitary hormones. A woman who is pregnant or becomes pregnant during a course of systemic or high-potency topical corticosteroid therapy should discuss safety issues with her dermatologist or obstetrician.

Note: A corticosteroid should only be used as prescribed. This medication should not be used more frequently or for a longer period of time than directed, and a corticosteroid should never be shared. This last fact is especially important for parents to know. Since atopic dermatitis tends to run in families, a parent with atopic dermatitis may believe that using a corticosteroid already in the home will help a child. This should never be done without consulting a dermatologist.

Cyclosporine
Cyclosporine is a potent immunosuppressant used to prevent rejection of a transplanted heart, kidney or liver. It also is used to treat severe cases of psoriasis and atopic dermatitis. In fact, oral cyclosporine has been used for many years to treat severe atopic dermatitis that does not respond to other treatment. In clinical trials, patients taking cyclosporine experienced prompt relief from the symptoms of eczema; however, rapid relapse usually occurs soon after the patient stops taking the medication. Long-term maintenance therapy tends to gives patients satisfactory remission.

A number of side effects, including lowered immune response, limit the use of oral cyclosporine. Due to potential side effects, each patient’s kidney function and blood pressure must be checked before the drug can be prescribed, and these need to be monitored regularly during therapy. Other side effects include increased risk of developing cancers, headache, tingling or burning sensations in the arms or legs, fatigue, abdominal upset and musculoskeletal or joint pain.

Topical preparations of cyclosporine are not available due to the medication’s inability to effectively penetrate the skin.

What it does: Reduces skin inflammation by inhibiting T-cell (a type of white blood cell) activity.

Usage: Take only as prescribed.

Interferon gamma
Not traditionally used to treat eczema, interferon gamma has been investigated in a small number of studies. Findings indicate that while injections can provide significant relief, a high overall rate of side effects was demonstrated. Interferon gamma is a protein produced by the human body that is involved in the regulation of the immune system and inflammatory responses.

What it does: More research is needed to fully understand how interferon gamma works. It is believed that interferon gamma regulates immune responses; thereby, preventing the overactive immune response that leads to inflammation of the skin.

Usage: Take only as prescribed.

Mycophenolate mofetil
Approved for preventing organ rejection in transplant patients, research suggests that the medication may effectively treat severe atopic dermatitis in adults. Potential side effects include increased risk of cancers and infections.

In animal studies, mycophenolate mofetil has been shown to cause birth defects. Women are advised to use effective contraception before and during therapy and for six weeks after stopping therapy with mycophenolate mofetil.

What it does: Prevents the exaggerated, one-sided immune response that leads to inflammation.

Usage: Take only as prescribed.

OTHER THERAPIES
Cold Compresses
A cold compress is a cloth dipped in ice water that is wrung out and applied directly to the skin that itches. When first placed on the skin, the itching or pain may become more intense; however, this soon subsides.

What it does: Helps relieve inflammation and itching.

Usage: If your dermatologist believes cold compresses are beneficial, the parent or patient will be instructed in how to use and how often to use.

Moisturizers
Most eczema treatment plans include use of moisturizers, also called emollients, since one of the symptoms of eczema is an intense almost unbearable itching.

Contrary to popular belief, moisturizers do not add moisture to the skin. Rather moisturizers serve as a barrier that reduces water loss from the skin. This is why dermatologists recommend that a moisturizer be applied after bathing while the skin is still damp. This “locks in” the moisture from the bath or shower. Moisturizers come in many, many forms. Ointments are best for very dry skin. Creams and lotions are used to treat mild to moderate eczema. Most moisturizers are applied directly to the skin; however, some are added to a bath.

Since many moisturizers contain added preservatives and fragrances that can irritate the skin, people with eczema should consult a dermatologist to find appropriate products.

What it does: Acts as a protective barrier to prevent water loss from the skin, which prevents the dry skin that leads to itching.

Usage: Moisturizer should be applied to the skin or added to a bath.

References
AAD Guidelines of Care for Atopic Dermatitis. July 26, 2003

MacReady, N. “Hydrocortisone Cuts Irritation Associated with Tacrolimus, Skin & Allergy News. February 2004, p. 28.

More Information
Doctor, why are you prescribing an ointment?
Explains the many forms that topical eczema medications can take and why

Phototherapy: A Treatment Option for Atopic Dermatitis
Discusses the types of phototherapy used to treat atopic dermatitis as well as the benefits and drawbacks

Preventing Flare-Ups
Lifestyle modifications that can help prevent flare-ups, includes links to guidelines for bathing and moisturizing, what you can do around the home that may help bring relief, stress-reduction techniques and more