What types of eczema treatment is available other than steroids?

For eczema management, you can broadly view it as treatment of the eczema rashes and maintenance of the condition.

For the treatment of eczema:

1. Topical steroids of various strengths are usually used for a short period of time to get the rashes under control. When used under supervision from your dermatologist, you are unlikely to develop serious side effects such as skin thinning etc.
2. In cases where there is an overlying infection, antibiotics or antiviral medicines may need to be used. Just using steroids in such cases actually lead to worsening of eczema.
3. There are steroid-sparing creams such as Protopic or Elidel ointment that can be useful in certain cases such as young children or sensitive areas such as the face. This allows treatment of eczema without the potential side effects that may be encountered with steroid creams.
4. Lastly, there are oral systemic agents that can be used for patients with difficult to control eczema. These may include cyclosporin, mycophenolate mofetil and methotrexate. The newest drug that has just entered the market in the last few months is Dupilimab (dupixent) which is an injection that helps patients with recalcitrant eczema. This is a promising new treatment for severe eczema that appears to be safe with only a few side effects.

For maintenance of eczema:

1. Regular use of the correct wash and moisturisers to improve the skin barrier is important. This helps the top layer of the skin keep its structure and has been shown to reduce the number of flares.
2. Identification and avoidance of triggers such as dust, heat, sweat or other known allergens can be helpful. Eg. If a patient is allergic to dog dander, their eczema is unlikely to improve unless the dog is removed from the patient's immediate environment.

I think that it’s important to have a good lifestyle, in the sense of avoiding situations that can make the skin worse, hot, and itchy.

It is also important to ensure that the skin is well moisturized and that we use a gentle cleanser. A lot of soaps commercially available can be very harsh for your eczema especially if your skin is very dry, and that worsens things.

So, lifestyle is very important and avoiding things like stress because we know that can be an important trigger as well.

In terms of medication prescribed, we always start with topical medication. The problem with eczema is that the skin is inflamed and it is important to try and reduce the inflammation. Topical moisturisers are very good in strengthening and improving the skin barrier, but it does not have much of an anti-inflammation fact.

That is why doctors prescribe steroids which are a good anti-inflammatory on the skin and reduce the inflammation of the skin. Now there are non-steroid options such as what Michelle mentioned, Protopic which do not have the side effects of thinning on the skin.

Unfortunately, steroids are something that most people fear. it is a two-edged sword where it helps inflammation and improves the skin but doctors are well aware of the side effects of continuous use of long term steroids can thin the skin and cause skin atrophy.

But when we use steroids, it is important to educate the patients, what strength are you using, how to use the steroids, how long are you using it for, when do you taper up or down. I think sometimes the problem is that doctors just throw the tube of steroids and say just use it, and the patients just use it, not knowing how to use it on the body.

So, I think education on steroids is extremely important to maximise the benefits and minimise the side effects of the steroids. So, we do use topical medication like steroids and non-steroid to control eczema.

But, of course, there are some cases where eczema can be very severe and I think the majority of people can be controlled mainly on the topical cream alone, but if they are not, and severe cases then phototherapy is an option, kind of entering a light booth and shining ultraviolet light 2-3 times a week and that helps to suppress some kind of inflammation on the skin.

But I think ultraviolet light on eczema is not universally successful for everybody, maybe about 50-60% may get some benefits from phototherapy. In severe cases, we move on to certain oral medications, like methotrexate, cyclosporine, and azathioprine and these are immunosuppressants.

As doctors, we do not just dish it out like that because we will make sure the indications are there and the eczema is severe and the impact on the quality of life is very bad, then we will consider these. And these immunosuppressants may have side effects like affecting your liver, or blood count, kidney or blood pressure.

Before starting on this we will discuss all the side effects and assess the patients to see whether there are any contraindications to using these medications. And when they are on the medications, they are closely monitored.

I would say it is an interesting time now for atopic eczema as there is a lot of research going on in this area. We know the immune system plays an important part. In atopic eczema, the immune system develops into what we call a Th2 immune response and that drives allergies and eczema. With this new knowledge, in the last 10-15 years, a lot of research has been going on about eczema.

Now they have been going on with the first biological treatment, which is called Dupixent which is an injectable, an antibody that binds with an interleukin, for an interleukin 13, which are chemical signals in the immune system which drives the Th2 response, by blocking the immune response that drives the allergy, you can actually help eczema.

So far, the data from Dupixent trials have been encouraging, about 75 % of patients have seen an improvement in their eczema. In terms of infections and internal organs toxicity in the liver, kidney it is hardly there. But people do get red-eye, which is seen in about 10% of the patients but these are new exciting new treatments as they are not steroids and they have seemingly less immunosuppressive than the traditional medications and so far, from the safety data it seems to be quite good.

Of course, we can't be sure of what will happen 10 years down the road, but we get more confident with the drugs that target other interleukins and others that hopefully give patients more options.