For Your Patients: Which Topical Treatments Work for Atopic Dermatitis?

Atopic dermatitis is one of the most common chronic inflammatory skin diseases worldwide and is also the most common form of eczema. Although infants and children are most often affected, adults can also develop atopic dermatitis, even in later life.

There is no cure, but proper treatment can help control symptoms. The condition is characterized by extremely dry, easily irritated skin, and patches of scaly rash that can develop anywhere on the face or body. Left untreated, the intense itching can impair sleep and lower quality of life, and scratching can result in lesions that crack and bleed, ooze and crust, setting the stage for potentially serious bacterial and viral infections.

The foundation of effective treatment for atopic dermatitis is good skin care. This includes bathing and use of an eczema-friendly moisturizer. Reducing exposure to "triggers" -- the irritants and allergens in the surrounding environment that cause flareups -- is also essential, along with use of prescription medication in the form of topical therapy -- that is, ointment or cream that is applied directly to the skin.

In the approximately 40% of patients who have moderate to severe atopic dermatitis, systemic medication taken orally or injected under the skin may also be required.

"Topical treatments remain one of the most popular options due to their effective track record and overall safety," said Robert Sidbury, MD, MPH, professor of pediatrics and chief of the Division of Dermatology, Department of Pediatrics, at the University of Washington School of Medicine and Seattle Children's Hospital.

There are several different classes of topical therapy for atopic dermatitis, and each one works differently. "Since each patient's atopic dermatitis is unique, board-certified dermatologists can determine the treatments that will work best for them," said Mark D. Kaufmann MD, immediate past president of the American Academy of Dermatology (AAD).

The following is a list of the topical therapies that are currently available:

Topical Corticosteroids

For the last 60 years, topical corticosteroids have been used with great success for the treatment of mild, moderate, and severe atopic dermatitis. There are seven classes of prescription steroids, based on different strengths ranging from "super potent" (Class 1), to "least potent" (Class 7).

The highest potency topical steroids include:

• Clobetasol propionate (Temovate) 0.05% ointment

• Halobetasol propionate (Ultravate) 0.05% cream, ointment, or lotion

• Diflorasone diacetate (Psorcon) 0.05% ointment

When used correctly, topical steroids rarely have serious side effects. Even high-potency steroids used to treat severe atopic dermatitis have minimal side effects. One of the most common side effects is a burning or stinging sensation when a topical steroid is applied to skin, but this tends to go away fairly quickly as treatment continues. Other possible side effects include thinning of the skin, stretch marks, spider veins, and acne or red rashes.

Topical Calcineurin Inhibitors (TCIs)

When steroids don't work, stop working, or simply aren't the right treatment, a growing number of topical "non-steroidal" medications can provide safe and effective options. TCIs are one of those options, and have been used for more than 20 years to treat the inflammation, redness, and itch associated with atopic dermatitis.

Pimecrolimus 1% cream is one of two TCIs currently available for the treatment of atopic dermatitis. It has been approved to treat mild to moderate atopic dermatitis for up to 12 months in adults and children age 2 and older.

The other TCI, tacrolimus 0.03% and 0.01% ointment, has been approved for up to 12 months of treatment for patients with moderate to severe atopic dermatitis. Tacrolimus 0.3% is for patients age 2 and older, and tacrolimus 0.1% is for those 15 and older.

As with topical steroids, the application of tacrolimus or pimecrolimus often causes the skin to burn and sting. This also tends to disappear in about a week as the skin heals.

TCIs have a good safety record when used as directed. In 2005, however, a cancer warning was placed on the packaging for tacrolimus and pimecrolimus. This followed reports that tacrolimus, when used as an oral transplant drug, was associated with a 10-fold increase in skin cancers and lymphomas. Topical application of tacrolimus and pimecrolimus do not appear to cause cancer, however.

Recently, experts from the AAD conducted a review of the latest safety data for TCIs as part of a 2022 update of guidelines for physicians on the use of topical therapies in atopic dermatitis. The conclusion was that topical use of tacrolimus and pimecrolimus in patients with eczema presented a cancer risk that was "likely not clinically meaningful."

Phosphodiesterase-4 (PDE-4) Inhibitors

In 2016, crisaborole (Eucrisa) 2% ointment was approved as a non-steroidal option for treating atopic dermatitis in infants as young as 3 months of age. This PDE-4 inhibitor works by blocking overactive PDE-4 enzymes that can lead to inflammation of the skin.

Crisaborole is a safe, effective non-steroidal option, particularly in younger children who are often more vulnerable to the adverse events associated with topical steroids. A thin layer of the ointment is usually applied twice a day to affected skin. Some patients report pain when applying topical crisaborole.

Crisaborole has proven to be a safe, effective non-steroidal option, particularly in younger children who are often more vulnerable to the adverse events associated with topical steroids. A thin layer of the ointment is usually applied twice a day to affected skin.

Janus Kinase (JAK) Inhibitors

In 2021, ruxolitinib (Opzelura) 1.5% cream was approved for short-term use in adults and children 12 years of age and older with mild to moderate atopic dermatitis. The JAK inhibitor also works by blocking enzymes that contribute to inflammation in the skin.

Topical ruxolitinib may be the most effective non-steroidal medication currently available for the treatment of atopic dermatitis and is equally or more effective than a medium-strength topical steroid. Like tacrolimus and pimecrolimus, however, ruxolitinib has a warning for a number of theoretical risks that can be discussed with your doctor.

Further information is available from the AAD and the National Eczema Association.

Read previous installments in this series:

For Your Patients: Atopic Dermatitis 101

For Your Patients: How Will My Doctor Diagnose Atopic Dermatitis?

For Your Patients: Skin Care to Control the Symptoms of Atopic Dermatitis in Children

For Patients: Identify Your Child's Atopic Dermatitis Triggers

"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this 12-part journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.