While the exact cause of eczema is not known, researchers understand that the immune system is involved. In eczema, the immune system overreacts and produces inflammation, which leads to symptoms such as itching, irritation and skin barrier problems.
If you have moderate to severe eczema, your doctor may prescribe a type of medication called an immunosuppressant, which helps control or suppress the immune system in order to slow down the symptoms of eczema.
Immunosuppressants are prescribed for moderate to severe atopic dermatitis (AD) in children and adults. They can be used to help stop the itch-scratch cycle of eczema, to allow the skin to heal and reduce the risk of skin infection.
There are a number of immunosuppressants, both traditional systemic medications and steroids, used for treating eczema
The inflammation of AD is caused in part by immune system messengers called cytokines that are increased in the blood and the skin. Several of these inflammatory cytokines exert their effects through a chemical signal pathway inside cells known as the JAK-STAT pathway (Janus Kinase-Signal transducer and activators of transcription). The JAK family has four members – JAK inhibitors can target one or more of these family members to block these immune signals and inhibit the inflammatory effect of key cytokines involved in AD. The following oral medications work by selectively blocking JAK1, which is a JAK family member associated with several cytokines and other pathways that drive inflammation and itch in AD.
Cibinqo (abrocitinib) is an oral JAK1 inhibitor approved by the FDA for adults with refractory moderate to severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics, or when use of those therapies is inadvisable. The FDA approved Cibinqo in January 2022. Frequently asked questions about Cibinqo are available here.
Rinvoq (upadacitinib) is an oral JAK1 inhibitor approved by the FDA for adults and adolescents aged 12+ years with moderate to severe AD whose disease is not adequately controlled with other system drug products, including biologics, or when use of those therapies is inadvisable. The FDA approved Rinvoq for AD in January 2022. Frequently asked questions about Rinvoq are available here.
Traditional systemic medications
Among the most common traditional systemic medications used to treat eczema are:
- Azathioprine is an oral medication first used in transplant patients to prevent the body from rejecting a transplanted organ.
- Cyclosporine is an oral or injectable medication first used in transplant patients to prevent the body from rejecting a transplanted organ.
- Methotrexate is an oral or injectable medication used frequently in psoriasis and different types of arthritis. It is a chemotherapy agent first used on cancer patients.
- Mycophenolate mofetil is used in transplant patients and for other diseases of the immune system.
These medications are considered “off-label,” which means that it’s not approved by the U.S. Food and Drug Administration (FDA) to specifically treat atopic dermatitis and other forms of eczema.
Immunosuppressants have the potential for serious side effects, including:
- Increased risk of infections
- Upset stomach and vomiting
- Increased risk for certain types of cancers
- Increased blood pressure with cyclosporine
- Increased risk of kidney damage with cyclosporine and methotrexate
- Risk of liver damage with methotrexate
Your healthcare provider will determine what baseline and ongoing monitoring exams and/or tests are needed when considering and using these medications.
In general, immunosuppressants are used for a short period of time to get the eczema under control, then tapered off or switched to topical medications for long-term eczema management. For many people, the improvement in their eczema on immunosuppressants helps to control symptoms with topical medications in the long term.
Steroids are also immunosuppressants and, in severe cases of eczema, oral steroids such as prednisone may be prescribed to control inflammation. However, they are not recommended by many healthcare providers due to the “rebound effect,” whereby the symptoms of eczema return, often worse, when the medication is discontinued. Long-term use (more than a month) of systemic steroids may result in serious side effects including:
- An increase in bacterial, fungal and viral infections
- Skin thinning, stretch marks and acne
- Hair loss
- Weight gain
- Glaucoma or cataracts
- High blood pressure
- Gastrointestinal issues
- Stunted growth in children
- Irregular menstruation
According to the Clinical Guidelines for the Treatment of Atopic Dermatitis by the American Academy of Dermatology, “Systemic steroids should be avoided if possible for the treatment of atopic dermatitis. Their use should be exclusively reserved for acute, severe exacerbations and as a short-term bridge therapy to other systemic, steroid-sparing therapy.”
If you are taking oral steroids for the short-term treatment of eczema, it’s important to work with your doctor to use and subsequently taper off this therapy appropriately and move to a longer-term treatment solution.
Visit our New Prescription Treatments hub to learn about newly-approved prescription eczema treatments.