Eczema Medication: Complete Guide to Treatment Options

What Are the Main Treatment Goals for Eczema?

The primary goals of eczema treatment are to reduce inflammation in the skin, restore the damaged skin barrier, relieve itching, and prevent future flare-ups. Treatment is typically stepped based on severity, starting with emollients and progressing to stronger medications as needed.

Eczema, also known as atopic dermatitis, is a chronic inflammatory skin condition that causes dry, itchy, and inflamed skin. The treatment approach depends on several factors including the type of eczema, your age, the location of the eczema on your body, and how severe your symptoms are. Understanding these treatment goals helps you work effectively with your healthcare provider to manage the condition.

The outermost layer of skin, called the stratum corneum, acts as a barrier protecting the body from irritants, allergens, and pathogens while preventing water loss. In eczema, this barrier is compromised due to genetic factors affecting proteins like filaggrin, combined with immune system dysregulation. Treatment therefore focuses on both repairing the barrier and calming the immune response.

A crucial aspect of eczema management that many patients underestimate is the importance of consistent daily skincare, even during periods when the skin appears healthy. This maintenance therapy significantly reduces the frequency and severity of flare-ups. Studies show that patients who continue regular emollient use between flares require less corticosteroid treatment overall.

Different Types of Eczema Medications

There are several categories of medications used to treat eczema, each working through different mechanisms:

• Emollients (moisturizers): These form the foundation of all eczema treatment, helping to restore the skin barrier and retain moisture
• Topical corticosteroids: Anti-inflammatory medications that reduce redness, swelling, and itching
• Calcineurin inhibitors: Non-steroidal immunomodulators safe for sensitive areas like the face
• Antibiotics: Used when eczema becomes infected with bacteria
• Systemic immunosuppressants: Oral medications for severe cases not responding to topical treatment
• Biologics: Targeted injectable medications that block specific inflammatory pathways
• JAK inhibitors: Newer oral medications that interrupt inflammatory signaling inside cells

How Do Emollients Work and Why Are They So Important?

Emollients (moisturizers) work by restoring the skin's protective barrier and trapping moisture in the skin. They contain ingredients like urea, glycerol, and propylene glycol that attract and retain water. Emollients should be applied liberally 3-4 times daily or more, using 250-500g per week for full-body application in moderate-to-severe eczema.

Emollients are the cornerstone of eczema management and should be used by everyone with the condition, regardless of severity. They work by filling the gaps between skin cells with lipids (fats) and creating a protective film on the skin surface. This dual action helps restore the damaged skin barrier characteristic of eczema while preventing transepidermal water loss (TEWL).

The active ingredients in emollients serve different purposes. Humectants like urea, glycerol (glycerin), and lactic acid draw water from the deeper skin layers and the environment into the stratum corneum. Occlusives like petrolatum and lanolin form a physical barrier that prevents water evaporation. Some emollients also contain sodium chloride or lactic acid, which help retain extra moisture in the skin through their osmotic properties.

Propylene glycol, found in many eczema emollients, has the additional benefit of inhibiting certain bacteria and fungi that can colonize eczematous skin. This antimicrobial effect can be particularly helpful since bacterial colonization, especially with Staphylococcus aureus, is common in eczema and can trigger or worsen flares.

Different Forms of Emollients

Emollients come in various formulations, each with different ratios of water to oil that suit different needs:

• Ointments: Highest oil content (80% oil, 20% water), most effective for very dry skin but can feel greasy
• Creams: Balanced mixture (50% water, 50% oil), versatile and cosmetically acceptable
• Lotions and emulsions: Higher water content, lighter feel, absorb quickly but may need more frequent application
• Gels: Water-based, cooling effect, good for hairy areas but less moisturizing

How to Apply Emollients Correctly

The technique for applying emollients matters as much as the product itself. Apply emollients generously using smooth, downward strokes in the direction of hair growth rather than rubbing vigorously, which can irritate the skin. After bathing or showering, pat the skin gently with a soft towel leaving it slightly damp, then apply the emollient immediately to lock in moisture.

Many people underuse emollients. Adults with moderate-to-severe eczema covering large body areas may need 250-500 grams (about half to one pound) of emollient per week. Keep emollients in multiple locations – by the sink, bed, and in your bag – to ensure consistent application. Applying emollient before it's needed is always better than waiting until skin feels tight and dry.

Possible Side Effects of Emollients

Emollients are generally very safe, but some people may experience mild side effects, especially when first starting treatment or when skin is particularly inflamed. Urea-containing products may cause stinging, warmth, redness, or a prickling sensation, particularly during the initial treatment phase when the skin barrier is most compromised. These symptoms typically diminish as the skin heals.

Rarely, some individuals may develop contact sensitivity to specific ingredients in emollient formulations. If you notice worsening symptoms with a particular product, discuss alternatives with your pharmacist or doctor.

What Are Topical Corticosteroids and How Should They Be Used?

Topical corticosteroids are anti-inflammatory medications that reduce inflammation and itching in eczema. They come in four potency classes from mild (Group I) to very strong (Group IV). Treatment typically starts with a stronger corticosteroid to quickly control symptoms, then steps down to maintenance with milder formulations. Always apply corticosteroid before emollient, or apply separately at different times of day.

Corticosteroids remain the most widely used and effective anti-inflammatory treatment for eczema. These medications work by suppressing the immune response in the skin, reducing the production of inflammatory chemicals, and decreasing the redness, swelling, and itching that characterize eczema flares. When used correctly, topical corticosteroids are safe and effective for both short-term flare management and longer-term maintenance therapy.

The anti-inflammatory mechanism of corticosteroids involves binding to receptors inside skin cells, which then affects gene expression to reduce production of pro-inflammatory cytokines and other mediators. This comprehensive effect on the inflammatory cascade explains why corticosteroids are so effective, but also why they must be used judiciously to avoid side effects from prolonged use.

Understanding that different corticosteroid formulations have dramatically different potencies is crucial for safe and effective treatment. The potency classification is based on vasoconstrictor assays, which measure how effectively the medication constricts blood vessels in the skin – a proxy for anti-inflammatory strength.

Corticosteroid Potency Classes

The percentage listed on corticosteroid packaging does not indicate potency – it only shows the concentration of active ingredient. A 0.01% very strong corticosteroid is far more potent than a 1% mild corticosteroid. Always follow your doctor's instructions regarding which strength to use on which body areas.

Choosing the Right Strength

Your doctor will select an appropriate corticosteroid strength based on several factors: the type and severity of your eczema, the body location being treated, your age, and how long you'll need treatment. The general principle is to use the mildest strength that effectively controls symptoms.

Certain body areas require special consideration due to thinner skin that absorbs medications more readily, increasing both effectiveness and risk of side effects. The face, neck, and skin folds (armpits, groin, under breasts) should generally only be treated with mild corticosteroids. The eyelids are particularly sensitive. Palms and soles, conversely, have thicker skin and may require stronger formulations for adequate penetration.

A common treatment approach is to start with a stronger corticosteroid to rapidly bring a flare under control – often within a few days – then step down to a milder formulation or non-steroidal alternative for maintenance. This "step-down" approach minimizes overall corticosteroid exposure while ensuring effective symptom control.

Application Technique: The Fingertip Unit

The "fingertip unit" (FTU) is a practical way to measure the correct amount of topical corticosteroid. One FTU is the amount of cream or ointment squeezed from a standard tube onto the tip of an adult index finger, from the crease to the fingertip – approximately 0.5 grams. Different body areas require different numbers of FTUs:

• Face and neck: 2.5 FTU
• One arm: 3 FTU
• One hand (both sides): 1 FTU
• One leg: 6 FTU
• Trunk (front or back): 7 FTU

When to Apply Corticosteroids

Timing and sequence of medication application affects absorption and effectiveness. If you're using both an emollient and a corticosteroid, there are two approaches: Either apply them at different times of day (for example, emollient in the morning, corticosteroid at night), or apply the corticosteroid first, wait 20-30 minutes for absorption, then apply the emollient.

Applying emollient immediately before corticosteroid can dilute the medication and reduce its effectiveness. However, well-hydrated skin does absorb topical medications better, so the emollient application from earlier in the day actually enhances corticosteroid absorption at the next application.

Don't Stop Treatment Too Early

One of the most common mistakes in eczema treatment is stopping corticosteroid use as soon as the skin looks better. The inflammation extends beneath the surface and can persist even when the visible signs have resolved. Stopping treatment prematurely often leads to rapid recurrence of symptoms.

Best practice is to continue applying corticosteroid for approximately one additional week on the face and two weeks on the body after the skin appears healed. Your doctor may also recommend tapering – gradually reducing application frequency or switching to a milder formulation – rather than abrupt discontinuation. This approach significantly reduces the likelihood of flare recurrence.

Side Effects of Topical Corticosteroids

When used as directed, topical corticosteroids are safe. However, prolonged use – particularly of stronger formulations – can cause local side effects. Skin thinning (atrophy) is the most common concern, making the skin more fragile and visible blood vessels more prominent. Stretch marks (striae) can occur, especially in skin folds. Some people develop steroid-induced acne, rosacea, or perioral dermatitis, particularly on the face.

The risk of side effects increases with stronger potencies, longer duration of use, application to thin-skinned areas, and use under occlusion (covering the treated area). Your doctor balances these risks against the significant benefits of controlling eczema inflammation, which itself damages the skin if left untreated.

What Are Calcineurin Inhibitors and When Are They Used?

Calcineurin inhibitors (tacrolimus and pimecrolimus) are non-steroidal immunomodulating medications that reduce inflammation without causing skin thinning. They're particularly useful for sensitive areas like the face and neck, and for long-term maintenance therapy. They work by blocking calcineurin, an enzyme that activates T-cells involved in eczema inflammation.

Calcineurin inhibitors offer an important alternative to corticosteroids, especially for treating eczema on delicate facial skin where long-term steroid use carries greater risks. These medications work through a completely different mechanism than corticosteroids – they inhibit calcineurin, an enzyme crucial for activating T-lymphocytes, which are key drivers of the allergic inflammation in eczema.

Two calcineurin inhibitors are available: tacrolimus (available in 0.03% and 0.1% ointments) and pimecrolimus (1% cream). Tacrolimus 0.1% has anti-inflammatory potency comparable to a moderately strong corticosteroid, while tacrolimus 0.03% and pimecrolimus are slightly less potent. Importantly, unlike corticosteroids, these medications do not cause skin thinning even with prolonged use.

Because they don't cause atrophy, calcineurin inhibitors are particularly valuable for treating eczema on the face, neck, and skin folds – areas where even mild corticosteroids must be used cautiously. They're also excellent for "proactive" maintenance therapy, where application twice weekly to previously affected areas can prevent flares from recurring.

How to Use Calcineurin Inhibitors

Apply a thin layer of calcineurin inhibitor to affected areas, usually twice daily. The medication often works relatively quickly, with improvement visible within a week for most patients. For maintenance therapy to prevent flares, application two to three times weekly to areas prone to eczema has proven effective in clinical trials.

Calcineurin inhibitors should not be used on infected eczema – if you have signs of skin infection (yellow crusting, spreading redness, pus), you'll need treatment for the infection first. These medications are not recommended for children under two years of age.

Side Effects of Calcineurin Inhibitors

The most common side effect is a burning, stinging, or prickling sensation at the application site, particularly during the first few days of treatment when the skin barrier is most compromised. This typically diminishes as the eczema improves and usually becomes tolerable within a week. Some patients find that refrigerating the medication reduces this initial discomfort.

Rarely, patients may experience redness or a sensation of heat at application sites after consuming alcohol. There is no evidence of increased skin cancer or lymphoma risk with topical calcineurin inhibitor use as originally theorized, according to long-term safety studies.

When Is Antibiotic Treatment Needed for Eczema?

Antibiotics are needed when eczema becomes infected, which is common because the damaged skin barrier allows bacteria to enter. Signs of infected eczema include worsening despite usual treatment, yellow crusting, weeping, spreading redness, and increased pain. Treatment may include topical antibiotic-corticosteroid combinations or oral antibiotics for more extensive infection.

Bacterial infection is a frequent complication of eczema, occurring because the compromised skin barrier allows bacteria – particularly Staphylococcus aureus – to colonize and infect the skin. Research shows that over 90% of people with atopic dermatitis have S. aureus colonizing their skin, compared to less than 5% of healthy individuals. When this colonization progresses to infection, it can trigger severe flares and prevent standard treatment from working.

Recognizing infected eczema is important because it requires different treatment. Warning signs include eczema that suddenly worsens or spreads despite treatment that usually works, yellow or golden crusting on the skin surface, weeping or oozing lesions, increased pain rather than just itching, and surrounding skin that's warm and red beyond the usual eczema patches.

Treatment depends on the extent of infection. Limited areas may respond to topical treatment – often a combination product containing both corticosteroid and antibiotic (such as fusidic acid), which addresses both the infection and underlying inflammation simultaneously. More widespread infection typically requires oral antibiotics, usually flucloxacillin or a related antibiotic effective against S. aureus, for 7-14 days.

Antiseptic Baths

For recurrent infections, antiseptic bath additives can help reduce bacterial load on the skin. Potassium permanganate baths (diluted to a pale pink color) have antibacterial, anti-inflammatory, and anti-itch properties. These can be done as full-body baths or localized soaks for hands or feet. Dilute bleach baths (about half a cup of regular bleach in a full bathtub) are also used, though this approach should be discussed with your healthcare provider first.

What Are the Options for Severe Eczema That Doesn't Respond to Topical Treatment?

Severe eczema not controlled by topical treatments may require systemic (whole-body) medications. Traditional options include immunosuppressants like azathioprine and methotrexate. Newer targeted treatments include biologics (dupilumab, tralokinumab) and JAK inhibitors (baricitinib, upadacitinib, abrocitinib), which offer high efficacy with better safety profiles for many patients.

When eczema remains severe despite optimized topical therapy including proper emollient use, appropriate strength corticosteroids, and calcineurin inhibitors, systemic treatment may be necessary. These medications work throughout the body to suppress the overactive immune response driving eczema. The decision to start systemic therapy is individualized, considering disease severity, impact on quality of life, and patient factors like age and other medical conditions.

Traditional systemic immunosuppressants have been used for decades and include azathioprine and methotrexate. These medications broadly suppress immune function and can be effective for eczema, but require regular blood monitoring due to potential effects on the liver and blood cell production. They are taken as tablets, usually once daily or weekly depending on the medication.

Biologic Medications

Biologics represent a major advance in eczema treatment, offering targeted therapy that blocks specific inflammatory pathways rather than broadly suppressing the immune system. Dupilumab (Dupixent) was the first biologic approved for moderate-to-severe atopic dermatitis and works by blocking interleukin-4 and interleukin-13, key cytokines in eczema inflammation. It's given as a subcutaneous injection every two weeks after initial loading doses.

Clinical trials show that approximately 70-80% of patients achieve significant improvement with dupilumab, with many achieving clear or almost clear skin. Itch typically improves rapidly, often within the first week or two. The medication has a favorable safety profile, with the most common side effect being injection site reactions. Some patients develop eye inflammation (conjunctivitis), which is usually manageable.

Tralokinumab (Adbry) is another biologic option, specifically targeting interleukin-13. It's also given by injection, initially every two weeks, potentially spacing to every four weeks for responders. Other biologics are in development, targeting additional inflammatory pathways involved in eczema.

JAK Inhibitors

JAK (Janus kinase) inhibitors are oral medications that block enzymes involved in inflammatory signaling inside cells. Unlike biologics that work outside cells, JAK inhibitors interrupt intracellular pathways that transmit signals from multiple inflammatory cytokines. This offers broad anti-inflammatory effects while maintaining relative specificity for immune pathways.

Several JAK inhibitors are now approved for moderate-to-severe atopic dermatitis: baricitinib (Olumiant), upadacitinib (Rinvoq), and abrocitinib (Cibinqo). These are taken as once-daily tablets, making them convenient for patients who prefer oral medication over injections. They often work quickly, with noticeable improvement in itch within days.

JAK inhibitors require monitoring for potential side effects including increased infection risk, changes in blood counts and liver function, and elevated cholesterol. Patients typically have blood tests before starting and periodically during treatment. These medications may not be appropriate for people with certain medical conditions or risk factors.

How Is Eczema Treated in Special Situations?

Special situations require modified approaches: facial eczema responds best to calcineurin inhibitors or mild corticosteroids; severely itchy eczema may benefit from sedating antihistamines at night; treatment during pregnancy requires careful medication selection; and seborrheic dermatitis (a different type affecting scalp and face) requires specific antifungal treatment.

Eczema on the Face and Neck

The face and neck require special attention because the skin is thinner and more visible, making it more susceptible to both eczema symptoms and treatment side effects. Strong corticosteroids should not be used on the face. Instead, treatment typically involves mild corticosteroids (hydrocortisone) for short periods during flares, with calcineurin inhibitors (tacrolimus or pimecrolimus) for longer-term maintenance.

Calcineurin inhibitors are particularly valuable for facial eczema because they don't cause skin thinning, perioral dermatitis, or steroid-induced rosacea – complications that can occur with prolonged facial corticosteroid use. Many dermatologists consider them first-line treatment for eczema affecting the face, eyelids, and neck.

Severely Itchy Eczema

Intense itching (pruritus) is often the most distressing symptom of eczema, disrupting sleep and quality of life. While treating the underlying inflammation is the most effective approach, additional measures may help. Sedating antihistamines like diphenhydramine or hydroxyzine don't reduce eczema itch directly but can help with sleep, breaking the itch-scratch cycle that worsens eczema overnight.

Non-sedating antihistamines (cetirizine, loratadine) are less helpful for eczema itch specifically, though they may help if you also have allergies contributing to symptoms. Both adults and children can be prescribed antihistamines when needed, though some children may paradoxically become restless rather than sedated.

Eczema During Pregnancy and Breastfeeding

Many eczema treatments are safe during pregnancy and breastfeeding, but some require caution. Emollients are completely safe and should be continued. Mild topical corticosteroids are generally safe; stronger corticosteroids should be used minimally or avoided, especially during the first trimester. Tacrolimus and pimecrolimus are generally avoided during pregnancy due to limited safety data.

If you're pregnant or breastfeeding and experiencing an allergic reaction, certain antihistamines like cetirizine and loratadine are considered relatively safe. Systemic treatments including biologics and JAK inhibitors are generally not recommended during pregnancy – discuss with your doctor before conceiving if you're on these medications.

Importantly, you should always use your prescribed emergency medications if you have a severe allergic reaction during pregnancy. The risk to you and your baby from a severe allergic reaction is greater than the risk from the medication.

Seborrheic Dermatitis (Dandruff Eczema)

Seborrheic dermatitis is a different type of eczema that affects the scalp, face (particularly around the eyebrows and nose), and sometimes the chest. It has different causes than atopic eczema – related to yeast on the skin – and requires different treatment, typically antifungal medications rather than the standard eczema treatments described above.

How Should I Apply My Eczema Medications?

Apply emollients liberally and frequently (3-4 times daily minimum), using smooth downward strokes. Apply immediately after bathing while skin is still damp. For topical medications, apply a thin layer using the fingertip unit method. Always apply emollient first, wait 30 minutes, then apply corticosteroid or other active medication.

Correct application technique significantly impacts treatment effectiveness. Many patients underuse emollients and overuse or misapply active medications, leading to suboptimal outcomes. Taking time to learn proper technique pays dividends in symptom control and minimizing medication use.

After bathing in lukewarm water (hot water dries skin), gently pat dry leaving skin slightly damp. Apply emollient immediately and liberally – a thick visible layer rather than a thin film rubbed in completely. Use smooth strokes in the direction of hair growth rather than vigorous rubbing. Allow the emollient to absorb for about 30 minutes before applying any active medication.

When applying topical corticosteroids or calcineurin inhibitors, use only enough to cover the affected areas with a thin layer. The fingertip unit system helps ensure you're using adequate (but not excessive) amounts. Apply only to actively affected areas, not prophylactically to currently healthy skin (unless specifically instructed by your doctor for maintenance therapy).