Comparing Two Topical Eczema Treatments

Key Points

• Eczema is a common chronic skin condition that affects millions of people all over the world.

• Two of the most common treatments for eczema are topical steroids and topical calcineurin inhibitors.

• This article provides an overview of both treatments and compares and contrasts them.

• Both treatments are effective for treating eczema, but some patients will benefit more from steroids, while others from calcineurin inhibitors or a combination of both.

• As with any eczema treatment, consult a dermatologist or other skincare professional to ensure it's right for you.

Eczema is a common, chronic skin condition involving itchy, inflamed, and sometimes painful skin. It disrupts day-to-day life and prevents sufferers from getting enough sleep. Eczema affects millions worldwide, so there's a massive demand for treatment and relief. Fortunately, various topical treatment options are available, but two of the most commonly used are topical steroids and topical calcineurin inhibitors.

This comprehensive guide compares these two approaches, exploring how they work, which patients are suitable candidates for each, potential side effects, the possibility of combining both treatments and the vital role healthcare professionals play in the decision-making process.

Although steroids and calcineurin inhibitors are proven treatments for eczema, they work differently. As with all medications, both may not work for everyone, and some patients may not respond to either.

Topical Steroids

Topical steroids, also known as corticosteroids, are among the most frequently prescribed treatments for eczema. They reduce inflammation, suppress the immune response, and alleviate itching. These medications come in various strengths, from mild to potent, depending on the severity of the condition.

Topical steroids inhibit the production of inflammatory substances, such as cytokines and prostaglandins, which play a crucial role in eczema flare-ups. They provide rapid relief from itching, one of the most distressing symptoms of eczema, allowing patients to avoid scratching, which can worsen the condition and lead to complications.

There are different classes of topical steroids, categorized by their potency. Mild steroids are typically prescribed for sensitive areas like the face, while more potent ones may be used on thicker skin, such as the palms or soles.

Topical Calcineurin Inhibitors

Topical calcineurin inhibitors, including tacrolimus (Protopic) and pimecrolimus (Elidel), are another class of medications used to treat eczema. Unlike steroids, they don't contain corticosteroids and work differently to manage eczema symptoms. Calcineurin inhibitors modulate the immune response. They suppress the activity of T cells in the skin, which are responsible for the inflammation seen in eczema.

Unlike steroids, calcineurin inhibitors have a lower risk of causing skin thinning (atrophy), making them suitable for long-term use, even on sensitive areas like the face and neck. They're instrumental in treating eczema on the face and other areas where the skin is thin and prone to side effects from steroids.

Identifying Suitable Candidates for Each Treatment

The choice between topical steroids and calcineurin inhibitors often depends on several factors, including the severity of the eczema, the patient's age, the location of affected skin, and the patient's general health.

Topical Steroids

Doctors commonly prescribe topical steroids in moderate to severe eczema cases. These medications quickly reduce inflammation and relieve itching. While corticosteroids are effective for short-term eczema relief in mild cases, doctors generally reserve them for acute flare-ups, as they carry a risk of severe side effects with prolonged use.

Due to the risk of skin thinning, doctors often avoid prescribing high-potency topical steroids for use on the face or to children, who have naturally thinner skin than adults.

Topical Calcineurin Inhibitors

Doctors often prefer calcineurin inhibitors for use on the face, neck, and other sensitive areas. Their lower risk of skin thinning makes them a safer option for prolonged use in these regions. Calcineurin inhibitors are considered safe for children as young as two, making them suitable for pediatric cases. In cases where topical steroids haven't provided relief, have caused adverse effects, or where specific steroid side effects should be avoided, calcineurin inhibitors present an effective alternative.

Side Effects and Safety

Topical steroids and calcineurin inhibitors have potential side effects that patients and healthcare providers should consider. Again, everyone is different, so a treatment that may cause serious side effects in one patient may be a godsend for another.

Topical Steroids

Prolonged use of potent steroids, especially on already thin areas, can lead to additional thinning, making skin more fragile and prone to bruising. Steroids can also contribute to developing stretch marks (striae), especially in areas with frequent application.

Additionally, the effectiveness of topical steroids may decrease over time. If so, the patient likely requires stronger formulations for the same relief. Some individuals may experience worsening symptoms and redness when discontinuing topical steroids abruptly, a condition known as topical steroid addiction or withdrawal.

Topical Calcineurin Inhibitors

A common side effect of calcineurin inhibitors, especially during the initial application, is a sensation of burning or stinging. While rare, there have been reports of increased susceptibility to skin infections with calcineurin inhibitor use. The FDA has issued a "black box" warning for calcineurin inhibitors due to concerns about a potential lymphoma and skin cancer risk. However, studies haven't definitively proven this association, and the risk appears very low.

Combining Both Treatments

Healthcare professionals may sometimes recommend combining topical steroids and calcineurin inhibitors for more effective eczema management. Combining these two treatments delivers synergistic benefits for many patients, effectively targeting inflammation through different mechanisms. Using a calcineurin inhibitor alongside a topical steroid can reduce the amount and potency of the steroid required, reducing the risk of side effects.

Doctors sometimes use calcineurin inhibitors as maintenance therapy to prevent flare-ups after initial steroid treatment. It's crucial to use combination therapy under the guidance of a healthcare professional. They can carefully assess a patient's needs and monitor for adverse effects.

Healthcare Professional's Role in Treatment Selection

A healthcare professional — dermatologist, pediatrician, general practitioner, etc. — should always be involved in eczema treatment selection. These medical professionals provide personalized guidance based on the patient's circumstances and health history. Here's how healthcare professionals play a vital role in the decision-making process.

Healthcare professionals can accurately diagnose eczema, determine its severity, and identify contributing factors such as allergies or sensitivities. They create individualized treatment plans tailored to the patient's age and underlying health, skin type, the location of the eczema, and its severity.

Healthcare professionals educate patients and caregivers about proper application techniques, potential side effects, and warning signs to watch for. They also monitor treatment progress and adjust the plan as needed.

They consider patient preferences and concerns when selecting treatment options, ensuring the chosen therapy aligns with the patient's lifestyle and goals. Healthcare professionals guide patients on long-term management strategies for chronic eczema to minimize flare-ups and maintain skin health.

Did You Know? Eczema and Pregnancy

The National Eczema Association (NEA) notes on its website that eczema during pregnancy is a fairly common occurrence. Interestingly, the majority of women who develop this condition while pregnant have no history of eczema, and researchers aren't quite sure why this is the case.

According to the NEA, however, "Eczema in pregnancy may occur because of changes in hormones and the immune system. During pregnancy, your body's immunity shifts to help keep the fetus safe. But this shift in immunity can make the mother more sensitive to allergens."

New Eczema Treatments Here, Others Coming

In recent years, a few novel eczema treatments have come to market. One of the most revolutionary has been a monoclonal antibody treatment known as Dupixent. Monoclonal antibody treatments use antibodies from the patient's own immune system and fuse them into a drug treatment.

Yale dermatologist Dr. Brett King told The Atlantic in August 2023 that Dupixent "[c]hanged the landscape of having eczema forever. Today, a half dozen novel treatments are available for the skin condition, all of which work by quieting the same biological pathway in eczema; dozens more are in clinical trials. Unlike older drugs, these new ones are precisely targeted and in many cases startlingly effective."

Making Eczema Yield to You

In the battle against eczema, topical steroids and calcineurin inhibitors are potent weapons. Each offers its own set of advantages and considerations. The choice between the two should be based on individual factors, including the severity of the condition, the patient's age and general health, and the location of the affected skin.

Healthcare professionals are crucial in diagnosing, assessing, and guiding patients through their treatment journey, ensuring the most effective and safe approach. In some cases, combining topical steroids and calcineurin inhibitors may offer the best results. Eczema management is a complex and ongoing process. However, with proper treatment and guidance, individuals can find relief, improve their quality of life, and even go about their daily business without giving much time or thought to eczema.

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