What to Do Next If Over-the-Counter Eczema Treatment Doesn't Work
No one knows exactly what causes the itchy, scaly, red, and generally unpleasant skin condition eczema. It’s probably a combination of genes, environment, and an overactive immune system, which might react to substances like soaps and fabrics.
What we do know is that there is a wealth of eczema treatments, including home remedies like warm baths, adequate sleep, and regular moisturizing, as well as over-the-counter antihistamines and creams.
For many, these strategies are enough to control eczema symptoms, but if you’ve exhausted all your options and eczema is still running your life, it’s probably time to look to prescription medications for help.
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“You need a prescription when everything else you’re doing isn’t working,” says Doris Day, MD, a dermatologist with Lenox Hill Hospital in New York City. “You’re moisturizing, you’re using every OTC [treatment] you can find, you adjusted your diet and sleep, you’re drinking more water, and the itch has become intractable.”
If those at-home and over-the-counter strategies haven’t helped, doctors will often start you on prescription cortisone creams, which are stronger than the versions you can buy over the counter. Cortisone is a type of steroid, and steroids have long been the gold standard in eczema treatment, Dr. Day says. “Of the products that have been available, steroid creams and ointments have worked faster and given more immediate relief.”
But they’re not perfect. Steroid creams can cause your skin to thin, so doctors typically prefer non-steroidal treatment for long-term eczema control, she adds. Those options might include topical calcineurin inhibitors (TCIs), which improve eczema by tweaking your immune system, or other non-steroidal creams, like crisaborole, to reduce inflammation.
When steroid creams aren’t cutting it, your doctor may decide to try oral steroids instead. “You get relief and better quality of life,” says Luz Fonacier, MD, a spokesperson for the American College of Allergy, Asthma, and Immunology and professor of medicine at SUNY Stony Brook. But there are downsides to oral steroids too: The meds can only be taken for short periods of time because of the risk of severe side effects like bone fractures, glaucoma, and even diabetes. Oral steroids also have a high rebound rate, with patients markedly improving while they’re on the drugs, then re-developing symptoms as soon as they come off, Dr. Fonacier says.
In general, doctors will want to see how you respond to treatment for two to four weeks before deciding to try another method, says Dr. Fonacier, who is also head of allergy and immunology at New York University Winthrop Hospital.
Some people might benefit from an immunosuppressant, a type of oral or injectable medication that tamps down the immune system. These drugs–which include cyclosporine and methotrexate–are used “off-label” for eczema, meaning they’re FDA-approved for treating other conditions. Immunosuppressants can cause side effects like an upset stomach or kidney damage, Dr. Fonacier says. Typically, these strong drugs are used for a short period of time to help get eczema under control; then it can be treated long-term with creams, according to the National Eczema Association.
A newer class of drugs, called biologics, may help when topical medications haven’t worked. Unlike immunosuppressants and oral steroids that suppress the entire immune system, biologics, which are usually given by injection, affect only a very small portion of the immune system. “The biologics are targeted and focus on the specific immune pathway that is out of sync,” says Dr. Day. So far, one biologic drug has been approved for eczema. Certain biologics, including some used for other skin conditions, may increase the risk for infections, says Dr. Day. “Sometimes testing is required before you start a biologic, and doctors may continue to monitor you for infections.”
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There’s one final time you might need a prescription treatment for eczema: if your skin becomes infected. Some people with eczema develop an infection from scratching. Eczema starts as an itch; it becomes more rash-like as you scratch. Eventually, “you just cannot not scratch it,” says Dr. Day. “The more you scratch, [the greater the chance that] the rash can become infected.” When that happens, your doctor may prescribe an antibiotic–in either cream or pill form–to quell the infection.