Understanding Eczema and Inflammation
Eczema, or atopic dermatitis, is a chronic inflammatory skin condition characterized by dry, itchy, and red skin [1.3.3, 1.7.2]. Inflammation is the body's immune response, but in eczema, this response is overactive, leading to persistent symptoms [1.7.2]. Anti-inflammatory medications are the cornerstone of treatment, working to suppress this immune activity, which in turn reduces itching, redness, and swelling, allowing the skin to heal [1.2.3, 1.7.2]. In the United States alone, approximately 31.6 million people have some form of eczema, with 9.6 million being children under 18 [1.9.1, 1.9.3]. The primary goal of using anti-inflammatory agents is to control flare-ups and maintain long-term remission [1.3.3].
Topical Corticosteroids: The First Line of Defense
Topical corticosteroids (TCS) are anti-inflammatory medications applied directly to the skin and are typically the first treatment prescribed for eczema [1.2.3, 1.11.1]. They work by suppressing the local immune response to interrupt the inflammatory cycle [1.2.3]. These medications come in various potencies, from mild over-the-counter (OTC) hydrocortisone to ultra-high-potency prescription formulations [1.2.2, 1.4.2].
- Low-Potency: Suitable for sensitive areas like the face and groin and for mild eczema. 1% hydrocortisone is available OTC [1.4.2, 1.10.1].
- Medium-Potency: Used for moderate eczema on the body [1.4.4]. Examples include triamcinolone acetonide and betamethasone dipropionate [1.2.2].
- High-Potency: Reserved for severe eczema or thicker skin on areas like the palms and soles of the feet [1.4.2].
Doctors recommend applying a thin layer once or twice daily until symptoms improve [1.2.3, 1.4.2]. While effective, long-term use can lead to side effects like skin thinning (atrophy), stretch marks, and changes in skin color [1.2.1, 1.11.1]. Ultra-high-potency steroids should not be used for more than three continuous weeks [1.4.4].
Non-Steroidal Topical Treatments
For patients who need long-term treatment or have sensitivities to steroids, non-steroidal options are a valuable alternative. These are particularly useful for delicate areas where steroid side effects are a concern [1.5.3].
Topical Calcineurin Inhibitors (TCIs)
TCIs work by blocking a protein called calcineurin, which is involved in activating the T-cells that cause inflammation [1.5.3]. They do not cause skin atrophy, making them a safer choice for long-term use on the face, eyelids, and skin folds [1.5.2, 1.5.3]. The two main TCIs are:
- Tacrolimus (Protopic): An ointment for moderate to severe eczema in adults and children over 2 [1.5.2, 1.5.3].
- Pimecrolimus (Elidel): A cream for mild to moderate eczema in individuals 3 months of age and older [1.5.3, 1.5.4].
The most common side effect is a temporary burning or stinging sensation upon application [1.5.1].
PDE4 Inhibitors
Phosphodiesterase 4 (PDE4) is an enzyme that helps regulate inflammation within skin cells. By blocking overactive PDE4, these inhibitors reduce the signs and symptoms of eczema [1.6.1].
- Crisaborole (Eucrisa): A 2% ointment approved for mild to moderate atopic dermatitis in patients aged 3 months and older [1.6.1]. It is a non-steroidal option that can be used on sensitive skin areas where steroids may be inappropriate [1.6.1].
Topical JAK Inhibitors
Janus kinase (JAK) inhibitors represent a newer class of anti-inflammatory treatment. They work by blocking the JAK-STAT signaling pathway, which is crucial for the immune responses that drive eczema inflammation [1.7.1].
- Ruxolitinib (Opzelura): A 1.5% cream approved for short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised patients 12 years and older whose disease is not adequately controlled with other topical prescriptions [1.2.4, 1.7.2]. It has been shown to rapidly reduce itch, sometimes within 12 hours of application [1.7.2].
Systemic Medications for Moderate to Severe Eczema
When topical treatments aren't enough to control symptoms, doctors may prescribe systemic medications that work throughout the body.
Biologics
Biologics are injectable medications made from living sources that target specific parts of the immune system responsible for inflammation [1.8.1, 1.8.2].
- Dupilumab (Dupixent): Blocks two key proteins, IL-4 and IL-13, involved in the inflammatory response [1.8.2]. It is approved for moderate-to-severe eczema in patients aged 6 months and older [1.8.2, 1.8.4].
- Tralokinumab (Adbry): Specifically targets IL-13 and is approved for adults and adolescents 12 years and older [1.8.1, 1.8.4].
- Lebrikizumab (Ebglyss): Also targets IL-13 and is approved for those 12 and older [1.8.4].
- Nemolizumab (Nemluvio): Targets the IL-31 receptor, which is heavily involved in the sensation of itch, and is approved for patients 12 and older [1.8.4].
Oral JAK Inhibitors
For moderate to severe eczema, oral JAK inhibitors can provide significant and rapid relief from inflammation and itch [1.7.2].
- Upadacitinib (Rinvoq) and Abrocitinib (Cibinqo) are once-daily pills approved for patients with moderate to severe atopic dermatitis [1.2.2, 1.7.4]. These medications are generally reserved for when other systemic drugs have failed due to a boxed warning from the FDA regarding risks of serious heart-related events, cancer, blood clots, and death [1.11.1].
Traditional Oral Immunosuppressants
For severe, difficult-to-control eczema, doctors may prescribe older immunosuppressive drugs like methotrexate, cyclosporine, and mycophenolate [1.2.1]. These are effective but require careful monitoring due to potential serious side effects, including kidney and liver problems and high blood pressure, and are typically used for short-term control [1.2.1, 1.11.1].
Comparison of Eczema Treatments
| Treatment Class | Mechanism | Best For | Key Side Effects |
|---|---|---|---|
| Topical Corticosteroids | Broad anti-inflammatory | First-line for all severities | Skin thinning, stretch marks, pigmentation changes [1.11.1, 1.11.3] |
| Topical Calcineurin Inhibitors | Blocks calcineurin, inhibiting T-cells | Sensitive areas, long-term maintenance | Temporary stinging/burning, increased light sensitivity [1.5.1, 1.11.1] |
| Topical PDE4 Inhibitors | Blocks PDE4 enzyme | Mild to moderate eczema, sensitive skin | Application site burning/stinging [1.6.1, 1.11.1] |
| Topical JAK Inhibitors | Blocks JAK-STAT pathway | Mild to moderate eczema not responding to other topicals | Bronchitis, ear infections, hives [1.11.1] |
| Biologics (Injectable) | Targets specific cytokines (e.g., IL-4, IL-13, IL-31) | Moderate to severe, long-term control | Injection site reactions, eye inflammation, cold sores [1.8.1, 1.11.4] |
| Oral JAK Inhibitors | Blocks JAK-STAT pathway systemically | Moderate to severe eczema, rapid itch relief | Nausea, headache, risk of serious infections, blood clots, heart events [1.7.1, 1.11.2] |
Conclusion
There is no single "best" anti-inflammatory for eczema, as the optimal treatment is highly individualized. It depends on the severity and location of the eczema, the patient's age, and their response to previous therapies [1.2.3, 1.4.2]. The foundational treatment for all eczema is consistent moisturizing to repair the skin barrier [1.3.3]. For flare-ups, topical corticosteroids remain the go-to initial therapy [1.2.3]. For long-term management and sensitive areas, non-steroidal topicals like TCIs, PDE4 inhibitors, and JAK inhibitors offer effective alternatives [1.5.1, 1.6.1, 1.7.2]. In cases of moderate to severe disease that don't respond to topical treatments, systemic options such as biologics and oral JAK inhibitors have revolutionized management, providing significant relief from debilitating symptoms [1.2.1, 1.8.2]. It is crucial to work with a healthcare provider to determine the most appropriate and safest treatment plan.
Authoritative Link: For more detailed information on eczema treatments, visit the National Eczema Association.
