Eczema is not fully understood and appears to be composed of multiple subtypes that may be distinct diseases. One common thread, however, is that the immune system is causing inflammation in the skin which leads to the itching, redness, and skin breakdown that is common to all forms of eczema.
Ideally, the cause of this aberrant immune function would be isolated and treated. While that is the goal for all, much to our frustration in the vast majority of cases an underlying or “root cause” cannot reliably be found. In severe cases, it may be of benefit then to stop the immune attack on the skin for some the following reasons:
- It allows the patient to have a break from the itch-scratch cycle which can have devastating effects on sleep, family, and work/school life
- It allows the skin to truly have a chance to heal without the constant attack of the immune system from within and scratching from the outside
- The risk of bacterial infection is greatly increased when the skin (the bodies’ natural barrier) is damaged and open. Although one might think that immunosuppressants would actually increase bacterial infections by suppressing the immune system, in the short term the opposite is true for the skin
- To take a break from powerful topical medications that can have undesirable side effects in patients who are needing to use them too frequently
Most doctors and patients would prefer to avoid these medications at all costs; however, in severe cases the risk-benefit ratio may warrant their consideration.
There are a number of immunosuppressants, but the three most commonly used for treating eczema are:
- Cyclosporine: a powerful medication used often for patients with a transplanted organ (such as kidney or heart). It works by specifically blocking an important pathway in the immune system, and has different side effects than steroids. This is generally used for less than 1 year in patients with eczema, in order to minimize the side effects.
- Methotrexate: a medication used frequently in psoriasis and different types of arthritis; it generally has fewer side effects than cyclosporine and can be used for longer periods. It seems to be less effective in general and often takes longer to show improvement than cyclosporine.
- Mycophenolate mofetil: a medication that is used as a “steroid-sparing” drug in transplant patients and for other diseases when the immune system is at fault. It may be the safest of all, but also tends to be less effective than cyclosporine, and may take 1-2 months to see improvement.
Immunosuppressants have a number of potential side effects, these include:
- Increased risk of dangerous infections, both bacterial (including tuberculosis) and viral (such as shingles)
- Upset stomach and vomiting
- Increased risk for cancers, both of the skin and internally, especially for those on higher doses for longer periods
- Increased blood pressure (cyclosporine), kidney damage (cyclosporine and methotrexate), liver damage (methotrexate)
There are many other possible side effects of these medications, and a careful discussion with your provider is necessary before embarking on this path. Frequent monitoring is often required, and your primary care physician should be involved as well.
In general, these medications are used for a number of months to get the disease under better control, and then are tapered off to give the body a rest, with hopes that the eczema remains milder. Fortunately, for many patients the brief improvement allows for more sustained control with safer topical medications in the long term.