What are topicals?
Topical treatments, or “topicals,” for eczema are medications that are applied to the skin to manage symptoms and reduce inflammation. There are a few different types of topicals for eczema. The most common include prescription steroids in varying strengths, calcineurin inhibitors, PDE4 inhibitors and Janus kinase (JAK) inhibitors.
Topical JAK inhibitor
The inflammation of atopic dermatitis (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 topical medication works by specifically blocking JAK1 and JAK2, two enzymes that are involved in several cytokine pathways that contribute to inflammation in the skin, itch, and skin barrier function. Reducing the activity of JAK1 and JAK2 in atopic dermatitis can lead to fewer and/or less severe signs and symptoms by reducing itch, rash, and skin redness.
One topical JAK inhibitor is available for use with eczema. Opzelura (ruxolitinib 1.5%) cream is a topical selective JAK inhibitor approved by the FDA for the short-term and non-continuous treatment of mild to moderate atopic dermatitis in non-immunocompromised (patients without weakened immune systems) adult and pediatric patients 12 years of age and older who disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Frequently asked questions about Opzelura (ruxolitinib 1.5%) cream are available here.
Topical calcineurin inhibitors
Topical calcineurin inhibitors (TCIs) are nonsteroidal medications that work by stopping certain cells of the immune system from “switching on,” preventing eczema symptoms such as redness and itch and inflammation.
Two TCIs are available for use in eczema, tacrolimus ointment (Protopic® and generic options) and pimecrolimus cream (Elidel® and generic options). Tacrolimus is FDA-approved in two concentrations for moderate to severe atopic dermatitis, one for children age 2-15 years of age, and one for adults. Pimecrolimus is FDA-approved for adults and children 2 years of age and older with mild to moderate atopic dermatitis. Your healthcare provider may additionally prescribe TCIs “off-label” to treat your eczema.
TCIs can be applied to all affected areas of the skin, including areas of delicate or thinner skin such as the face, eyelids, genitals, or skin folds, where the short- or long-term use of topical steroids may not be preferred. TCIs can be used for extended periods of time to control symptoms and reduce flares. Common side effects with TCIs include mild burning or stinging sensation when the medication is first applied to the skin.
In 2006, the FDA implemented a black box warning for TCIs regarding long-term safety and a possible risk of lymphoma (a type of blood cancer). To date, a causal link between TCIs use in eczema and these cancers has not been shown. However, this risk should be discussed with your healthcare provider.
Topical PDE4 inhibitors
Phosphodiesterase 4 (PDE4) is an enzyme that works inside cells in our immune system in the production of different inflammatory cytokines. Cytokines are proteins also produced by different immune system cells that contribute to a normal immune response. When cytokines are mistakenly triggered in the body, the resulting inflammation can contribute to the development of certain diseases, including atopic dermatitis. Blocking PDE-4 hinders the production of several cytokines that are involved in the inflammation of atopic dermatitis.
Currently, there is one FDA-approved topical PDE4 inhibitor for atopic dermatitis. Crisaborole (Eucrisa®) is an ointment available for adults and children with mild to moderate atopic dermatitis ages 3 months and up. Frequently asked questions about Crisaborole are available here.
One of the most commonly prescribed medications for all types of eczema is topical corticosteroids, or steroids for short, which can reduce inflammation and itching so that the skin can begin to heal.
Steroids are naturally occurring substances that our bodies make in order to regulate growth and immune function. Corticosteroids have been used for more than 60 years in topical medications to treat many kinds of inflammatory skin conditions including eczema. Topical steroids are used for eczema in adults and children.
Topical steroids are classified by their strength (or potency), which ranges from “super potent” (Class 1), to “least potent” (Class 7). There are a number of different topical steroid types as well as different concentrations, and dosage forms (ointment, cream, lotion, spray).
Only apply the steroid to eczema-affected areas of your skin at the frequency prescribed by your doctor. Moisturizers can be applied on top of steroids.
Certain areas or types of skin — the face, genitals, skin folds, raw or thin skin, and areas that rub together, such as beneath the breasts, or between the buttocks or thighs — absorb more medication and care must be taken when using steroids in these areas.
Once inflammation is under control, reduce or stop using the steroid per your physician’s instructions. If you are using high-potency steroids and/or have been using steroids for a long time, please consult your healthcare provider to avoid the risk of a “rebound” flare after stopping the medication.
As with any medication, there can be side effects to using topical steroids. The risk of side effects is related to the potency of the steroid, location and duration of use. Many of the potential side effects will resolve after stopping use of topical steroids.
Common side effects of topical steroids include:
- Thinning of the skin (atrophy)
- Stretch marks (striae)
- Spider veins (telangiectasia)
- Perioral dermatitis (around the mouth)
- Acne or rosacea-like rashes
Rare side effects of topical steroids may include:
- Hypothalamic-pituitary-adrenal axis suppression
- Growth retardation in young children
- Glaucoma (damage to the eye’s optic nerve)
- Cataracts (clouding of the eye lens)
- Topical Steroid Withdrawal
Corticosteroids, including topical corticosteroids (TCS), are associated with a potentially serious condition called Topical Steroid Withdrawal (TSW). TSW is thought to be rare but can be debilitating for some patients. It may not be recognized by all health professionals as clear diagnostic criteria do not yet exist. Learn more about TSW and appropriate use of TCS.
Visit our New Prescription Treatments hub to learn about newly-approved eczema treatments.