Eczema Essentials: More than Skin Deep

MAY 18, 2015
Debra Freiheit, RPh
Although eczema is not curable, it is controllable.
More than 30 million Americans have eczema (atopic dermatitis),1 and the incidence is increasing.2 According to the Centers for Disease Control and Prevention, eczema in children nearly doubled between 2000 and 2010.3

Eczema is characterized by itching, redness, papules/vesicles, crusts or lichenifications, spongiosis, keratosis, and skin thickening.4 It is neither contagious nor curable, but it is controllable.1,4 Management is challenging, however, trying to control acute symptoms and prevent flares while avoiding adverse effects (AEs).4 Topical corticosteroids (TCs) are the mainstay of pharmacologic treatment, but calcineurin antagonists may be preferred for certain applications.4 Liberal use of moisturizers is universally recommended,5 and multiple topicals with different mechanisms of action may be used concomitantly.5 Systemic treatment is generally reserved for severe or difficultto- treat cases.4 The American Academy of Dermatology notes that clinical judgment needs to be used, as there is still much to be discovered.5

Hydrating the Skin
A dysfunctional epidermal barrier is a key eczema feature.4,5 Moisturizers can be the primary treatment for mild disease and should be part of all regimens.7 They improve hydration and decrease both irritation and the need for prescription medications.5 Ideal amounts and frequencies have not been studied, but regular and generous application is generally recommended.5 Prescription emollients, such as Biafine, Kerol, and EpiCeram, mimic natural compounds; they have a structural role as a skin barrier rather than a pharmacologic effect.5

Bathing is both treatment and maintenance. Although it can hydrate and remove irritants, water evaporation may cause greater moisture loss. It is not clear if baths or showers are better.5 Bleach baths may help, and do not cause antibiotic resistance.5 Wet wraps, which can be worn up to 24 hours, decrease flares and are well tolerated.4,5 Instruct patients to towel dry.5

Topical Corticosteroids Are the Gold Standard
TCs are the mainstay of therapy; they suppress inflammation and relieve itching, and may be needed for months or even years.4-6 Patients often have fear or anxiety associated with using TCs, particularly regarding skin thinning, systemic absorption, and effects on growth and development.6 Over 70% of patients expressed concern, and 24% admitted nonadherence because of those concerns, according to study results.5,6 A common misconception is that TCs are the same as anabolic or oral steroids.6 Addressing concerns with facts may improve adherence and efficacy.5

TCs come in a wide variety of potencies and formulations (Online Table 1) and can be applied to inflamed skin as needed.4,5,7 There is no clear superior agent or regimen, and quantities and frequencies of use are highly varied. Sometimes a short course of a high-potency agent with a quick taper is used; other times, a low-potency agent is used first and dosing is increased or a stronger agent is used, as needed. During severe flares, short courses of mid-or high-potency TCs can provide rapid relief, but less potent agents are preferred for long-term treatment. 5 Twice-daily dosing is most common,7 but once-daily dosages may be just as effective.5 More frequent administration does not improve efficacy.7 Pulse application of potent agents (eg, only weekends, every other week), drug holidays, and use of steroid-sparing drugs may decrease systemic effects.8

Table 1: Relative Potencies of Topical Corticosteroids

Lowest Potency (VII) Mild (VI) Lower Mid-strength (V) Mid-strength (IV) Upper Mid-strength (III) Potent (II) Superpotent (I)
Dexamethasone cream 0.01% Alclometasone ointment, cream 0.05% (Aclovate) Betamethasone dipropionate lotion 0.05% (Diprosone, Maxivate) Fluocinolone ointment 0.025% (Synalar) Amcinonide 0.1% cream or lotion (Cyclocort) Amcinonide 0.1% ointment, lotion, cream (Cyclocort) Betamethasone dipropionate ointment and cream 0.05% (Diprolene, Diprosone)
Hydrocortisone acetate 0.5%-2.5% (Hytone, Cortaid, etc) Betamethasone valerate lotion 0.05% (Valisone) Betamethasone valerate cream, lotion 0.01% (Valisone) Flurandrenolide ointment 0.05% (Cordran) Mometasone ointment 0.1% (Elocon) Desoximetasone cream or ointment 0.25%, or gel 0.05% (Topicort, Ibaril) Clobetasol ointment, cream 0.05% (Temovate, Clobex, Cormax, Embeline, Olux)
Methylprednisolone 1% Desonide cream 0.05% (Desowen, Verdeso, Desonate) Fluocinolone oil 0.01% (Derma-Smoothe) Halcinonide cream 0.025% (Halog) Betamethasone valerate ointment, foam 0.1% (Valisone, Luxiq 0.12%) Diflorasone ointment 0.05% (Florone) Diflorasone ointment 0.05% (Psorcon)
Prednisolone Fluocinolone cream, solution 0.01% (Synalar, Derma-Smoothe) Flurandrenolide cream 0.05% (Cordran) Hydrocortisone valerate ointment 0.2% (Westcort) Diflorasone cream 0.05% (Florone, Psorcon) Fluocinonide ointment, cream, gel 0.05% (Lidex) Halobetasol ointment, cream 0.05% (Ultravate)
    Fluticasone cream 0.05% (Cutivate) Mometasone cream, lotion 0.1% (Elocon) Fluticasone ointment 0.005% (Cutivate) Halcinonide cream, ointment, shampoo 0.1% (Halog) Fluocinonide cream 0.1% (Lidex)
    Hydrocortisone butyrate cream, ointment, gel 0.1% (Locoid) Triamcinolone ointment 0.1% (Kenalog, Aristocort) Fluocinonide cream 0.05% (Lidex) Triamcinolone ointment 0.5% (Kenalog)  
    Desonide ointment 0.05% (Desowen) Fluocinolone cream 0.025% (Synalar) Triamcinolone ointment, cream 0.1% (Aristocort)    
    Prednicarbate cream 0.1% (Dermatop) Hydrocortisone valerate cream 0.2% (Westcort) Triamcinolone cream 0.05% (Aristocort)    
    Fluocinolone cream 0.025% (Synalar, Derma-Smoothe) Desoximetasone emollient cream 0.25% (Topicort) Desoximetasone Cream 0.05% (Topicort)    
    Triamcinolone lotion, cream 0.1% (Kenalog)   Betamethasone valerate lotion 0.01% (Valisone, Luxiq)    
    Triamcinolone diacetate cream 0.1% (Aristocort)        

Adapted from references 5, 10, 11, 14.

AEs such as atrophy, striae, telangiectasia, purpura, blanching, acneiform and rosacea-like eruptions, and abnormal hair growth are related to potency, amount used, duration of use, patient age, occlusive dressing use, administration vehicle, and addition of other forms of corticosteroids (inhaled, intranasal, and systemic).5,7,8 Skin thinning is more likely with higher-potency medications, the use of occlusive dressings, and use on thinner skin (such as with elderly patients).5,8 Potent or very potent TCs are more likely to decrease adrenal function; however, faster restoration of skin integrity decreases systemic effects.4 Pituitary suppression is low, and hyperglycemia and hypertension are rare.5 Cushing’s symptoms are also rare, and mostly reported in infants.8 Effects on children’s final height are not clear at this time.5 Cataracts and glaucoma have been reported with systemic steroid use, but have not been noted with topical corticosteroids.5 Contact dermatitis may occur with TC use7,9; consider the possibility if patients are not getting relief, particularly if the application area does not heal or worsens.9 Inactive ingredients (particularly propylene glycol or preservatives) may be to blame.5 AEs are mostly reversible (within months) with discontinuation of TCs,5 with the exception of striae.7 Rebound dermatitis has been reported with abrupt discontinuation.7

Itch is the primary symptom used to evaluate the success of TCs; do not taper therapy until itching has resolved. To avoid rebound, taper gradually by reducing the frequency and/or the potency of the TC used.4