Atopic Dermatitis (Eczema) Medications: Topical Steroids and Other Types to Know
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Atopic Dermatitis Medications: Topical Steroids and Other Types to Know

Atopic Dermatitis Medications: Topical Steroids and Other Types to Know
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Updated on June 10, 2024
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There is no cure for atopic dermatitis, the most common form of eczema. Instead, treatment can help reduce symptoms and establish long-lasting disease control.

While atopic dermatitis treatment plans often include at-home skin-care routines, such as moisturizing the skin, medications also play a vital role in reducing itch and inflammation.

There are a number of different types of medications for atopic dermatitis, including topical medications, oral immunosuppressants, and injectable drugs.

Topical Treatments for Atopic Dermatitis

Topical treatments (or “topicals”) are medications that you apply to the skin to reduce or control atopic dermatitis symptoms.

Topical Steroids

Corticosteroids, also known simply as steroids, are a first-line anti-inflammatory topical treatment for atopic dermatitis. These drugs can help relieve itch and reduce inflammation. Topical steroids come in various forms — ointments, creams, lotions, sprays, gels, and oils. They are also available in various strengths, which range from class 1 (super potent) to class 7 (least potent).

Commonly prescribed topical steroids include:

  • Low-potency steroids, such as hydrocortisone (low-dose hydrocortisone is available over the counter)
  • Moderate-potency steroids, such as prednicarbate, methylprednisolone, and triamcinolone
  • High-potency steroids, such as betamethasone and mometasone
  • Ultra-high-potency steroids, such as clobetasol
Topicals should only be used as directed by your doctor in order to avoid side effects. “Topical steroids do have side effects with prolonged use, such as skin thinning, stretch marks, and the development of telangiectasias [spider veins],” says Kanwaljit K. Brar, MD, a pediatric allergist and immunologist at NYU Langone in New York City. Other common side effects of topical steroids include perioral dermatitis around the mouth, and acne or rosacea-like rashes.

Rarely, they can also cause more serious side effects, including glaucoma and cataracts, adrenal suppression, and topical steroid withdrawal, among other things. “However, they are currently the most effective treatment of skin inflammation and should be used under the guidance of an experienced doctor,” adds Dr. Brar.

If steroids are used at the correct dose and only for a short period of time during a flare, they rarely lead to side effects.

Topical Calcineurin Inhibitors (TCIs)

TCIs are nonsteroidal anti-inflammatory medications that work by blocking an overactive immune system when absorbed into the skin.

The drugs are typically prescribed for sensitive areas such as the genitals or the face, or when topical steroids are ineffective or aren’t well tolerated (though they aren’t necessarily more effective than steroids in general).

The two types of TCIs approved by the U.S. Food and Drug Administration (FDA) are tacrolimus (Protopic) and pimecrolimus (Elidel). While TCIs don’t have the same side effects as topical steroids, they may cause a mild burning or stinging sensation when first applied.

In 2006, the FDA added a box warning for TCIs because of a potential increased risk of lymphoma with oral calcineurin inhibitors. However, a systematic review and meta-analysis published in 2023 found moderate-certainty evidence showing that TCIs don’t increase the risk of cancer among people with atopic dermatitis.

PDE4 Inhibitors

Crisaborole (Eucrisa) is in a class of drugs known as PDE4 inhibitors. These drugs work by blocking the enzyme phosphodiesterase 4, which is involved in the body’s inflammatory processes.

In clinical trials, Eucrisa helped one-third of patients get clear or almost clear skin after 28 days of treatment. Less than 2 percent of patients experienced side effects that forced them to stop using the drug. The most common side effect was application site pain, including burning or stinging.

Possible serious side effects include hypersensitivity reactions to Eucrisa’s active ingredient, crisaborole.

Topical JAK Inhibitors

Inflammation, a common symptom of atopic dermatitis, is partly caused by elevated levels of cytokines, or immune system messengers, in the blood and skin.

Ruxolitinib (Opzelura), the only topical JAK inhibitor approved by the FDA to treat atopic dermatitis, blocks JAK1 and JAK2, two enzymes that are involved in the pathways of several cytokines, thereby reducing itch, rash, and redness. In 2021, the FDA approved ruxolitinib for patients 12 years of age and older.

The FDA added a box warning to this medication because of the risk of serious infections and other potentially severe complications associated with oral JAK inhibitors.

Oral Medications for Atopic Dermatitis

There are a variety of prescription oral medications for atopic dermatitis. Systemic immunosuppressants help suppress the immune system in order to stop the itch-scratch cycle, while oral immunomodulators block immune signals to reduce inflammation and itch. Oral steroids are another option for short-term use.

Systemic Immunosuppressants

Systemic immunosuppressants are a type of medication that helps control or suppress the immune system. Typically prescribed for moderate to severe atopic dermatitis, they can help stop the itch-scratch cycle to allow the skin to heal and reduce the risk of infection.

The most commonly used systemic immunosuppressants for atopic dermatitis are cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil. When used for atopic dermatitis, immunosuppressants are considered “off-label” because they are not approved by the FDA to specifically treat the condition.

Though they are effective for some people, systemic immunosuppressants are not advised for long-term use. The drugs carry a number of potentially serious side effects, including increased risk of infections and certain types of cancer, increased blood pressure (cyclosporine), increased risk of kidney damage (cyclosporine and methotrexate), and risk of liver damage (methotrexate).

Oral Steroids

Steroids are also immunosuppressants, and oral steroids such as prednisone may be prescribed to control inflammation in severe cases of atopic dermatitis.

However, oral steroids may have serious side effects, especially if they are used for long periods of time. In fact, many healthcare providers don’t recommend oral steroids due to the “rebound effect,” where atopic dermatitis symptoms return — sometimes worse than they were before — when you stop taking the medication. Using oral steroids for more than a month may cause side effects including:

  • An increase in bacterial, fungal, and viral infections
  • Skin thinning, stretch marks, and acne
  • Hair loss
  • Weight gain
  • Glaucoma
  • Cataracts
  • High blood pressure
  • Gastrointestinal (stomach) issues
  • Osteoporosis
  • Stunted growth in children
  • Irregular menstruation

Oral JAK Inhibitors

As previously mentioned, cytokines are immune system messengers that can lead to inflammation when elevated in the blood and skin, as in atopic dermatitis. JAK inhibitors are a relatively new class of oral immunomodulators that can block these immune signals and thereby reduce inflammation and itch.

The oral JAK inhibitors currently approved for treatment of moderate to severe atopic dermatitis are upadacitinib (Rinvoq) and abrocitinib (Cibinqo). Like with topical JAK inhibitors, the FDA has placed a box warning on these medications for potentially increasing the risk for all-cause mortality, serious infections, certain cancers (including lymphoma), heart attack, stroke, and thrombosis.

Rinvoq and Cibinqo are not recommended for use in combination with other JAK inhibitors, biologics, or other immunosuppressants.

You should not breastfeed while taking abrocitinib or upadacitinib.

Biologics

Biologic drugs, or biologics, essentially use human DNA to create antibodies to treat certain diseases at the immune system level, making them among the most targeted therapies available to treat atopic dermatitis. These drugs are injected subcutaneously (through the skin) or intravenously (in the vein).

Biologics work by blocking the activity of the protein interleukin, which normally helps the immune system fight off pathogens with inflammation but is triggered erroneously in people with atopic dermatitis and other inflammatory conditions.

Two biologic drugs are approved by the FDA for the treatment of atopic dermatitis.

Dupilumab (Dupixent) is approved for adults and children aged 6 months and older with moderate to severe atopic dermatitis for whom topical treatments have not worked or are not recommended. It is administered by injection under the skin. In adults and children 6 years and older, the initial dose is two injections, followed by one injection every two or four weeks.

In clinical trials, more than half of people who took Dupixent — which is injected under the skin every other week — had their symptoms reduced by 75 percent over the course of 16 weeks.

The most common side effects of Dupixent include:

  • Eye and eyelid inflammation, sometimes with blurry vision
  • Dry eye
  • Injection site reactions
  • Cold sores on the mouth or lips
  • High count of eosinophil, a white blood cell
Serious side effects can include:

  • Allergic reactions
  • Eye problems
  • Blood vessel inflammation (In rare cases in people with asthma)
  • Joint aches and pain
Tralokinumab-ldrm (Adbry) is another biologic that is FDA approved for adults and children 12 years of age and older with moderate to severe atopic dermatitis that can’t be adequately controlled with topical therapies or when those therapies are not recommended.

Adults using Adbry receive an initial loading dose of four injections on the first day of treatment, followed by two injections that you give yourself at home every other week. After four months, this may be changed to two injections every four weeks.

The most common side effects of Adbry include:

  • Upper respiratory tract infections
  • Eye and eyelid inflammation
  • Reaction at the injection site
  • High eosinophil count

Serious side effects may include:

  • Allergic reactions, including anaphylaxis
  • Eye problems

Over-the-Counter Medications for Treating Atopic Dermatitis

Antihistamines

If allergies are triggering your atopic dermatitis, antihistamines may help relieve itching and inflammation. Some antihistamines also contain sedatives that can help people with atopic dermatitis get a better night’s sleep.

Pain Relievers

Over-the-counter pain relievers like acetaminophen (Tylenol), ibuprofen (Advil), and naproxen (Aleve) can also help relieve atopic dermatitis symptoms.

Common Questions & Answers

What is the purpose of treating atopic dermatitis?
Treatment aims to reduce eczema symptoms, particularly itchiness, and establish long-term disease control. The ultimate goal is to allow individuals to resume their normal daily activities.
Prescription medications can help reduce symptoms including inflammation and itch. They come in different types, including topical creams, oral immunosuppressants, and injectable drugs.
Potential side effects include skin thinning, stretch marks, and the development of spider veins. In rare cases, these medications can cause glaucoma, cataracts, adrenal suppression, and topical steroid addiction and withdrawal.
Topical medications for atopic dermatitis include topical calcineurin inhibitors (TCIs), PDE4 inhibitors, and JAK inhibitors. They work differently but are generally used to reduce inflammation and itching.
Oral medications include immunosuppressants (most commonly cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil) and JAK inhibitors, such as upadacitinib (Rinvoq) and abrocitinib (Cibinqo), as well as oral steroids. These drugs work in different ways to limit inflammation and itching.
EDITORIAL SOURCES
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Resources
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  3. Devasenapathy N et al. Cancer Risk With Topical Calcineurin Inhibitors, Pimecrolimus and Tacrolimus, for Atopic Dermatitis: A Systematic Review and Meta-Analysis. The Lancet Child & Adolescent Health. January 2023.
  4. Eczema Treatment: Crisaborole (Eucrisa®) Ointment. American Academy of Dermatology Association. January 31, 2023.
  5. FDA Approves Eucrisa for Eczema. U.S. Food and Drug Administration. December 14, 2016.
  6. New Drug Application Approval. U.S. Food and Drug Administration. September 21, 2021.
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  11. Dupixent (dupilumab) Injection. Dupixent.
  12. FAQ – Adbry (Tralokinumab-ldrm). National Eczema Association.
  13. Getting Started & Staying on Adbry. Adbry.