The itch of eczema is maddening. It’s an old disease we are continually learning more about. Many consider it an autoimmune disease; others say it is caused by a defective skin barrier. Which came first? Or perhaps they are two different aspects of the disease process.

Since the 1950s, topical steroid creams have been the mainstay in treating eczema rashes. While corticosteroids remain the standard of care and still work well for the majority of patients, it’s exciting to finally see development of new classes of medications for this group of skin conditions, the most common being atopic dermatitis (AD). The new developments are important because of skin atrophy concerns with long-term use and because some patients need something stronger than steroids to keep it under control.

JAK inhibitors for atopic dermatitis. Janus kinase inhibitors are the most promising development for eczema in years. This class of drugs has received FDA approval for rheumatoid and psoriasis arthritis, ulcerative colitis and other autoimmune conditions. JAK inhibitors work by blocking the Janus kinase group of enzymes from attaching to immune cell receptors, which would otherwise create a cascade of inflammatory cytokine proteins, leading to inflammation. Pfizer is expecting FDA approval this April of abrocitinib, an oral JAK1 inhibitor for moderate-to-severe atopic dermatitis. Two other oral JAK inhibitors and one topical are in the end stages of clinical investigation.

Biologic immune-modulating therapy. Dupixent (dupilumab), a monoclonal antibody injection, is among the newer medications available to help patients with moderate-to-severe eczema not managed by topicals. Only in use since 2017, this immune-modulating biologic is not yet widely prescribed, mostly because of price, but also due to the side effect of itchy, watery eyes. Other biologics for atopic dermatitis are in development.

Non-steroidal cream avoids skin atrophy issues. A relatively new non-steroidal option for managing eczema is Eucrisa (crisaborole). This boron-based anti-inflammatory topical is great because it provides effective relief with a high safety profile without the side effects of steroidal creams. I was excited to serve as a principal investigator in the clinical study for FDA approval of this medication, but it is not yet widely prescribed because it is pricey. That will change in a few years. Eucrisa was eligible for patent challenges this past December, and a generic may be available by late 2026.

New studies show Elidel and Protopic risks are low. Topical immunosuppressant creams are the second line of defense for those whose condition is not managed well by topical steroids. In 2006, two of these medications – Elidel (tacrolimus) and Protopic (pimecrolimus) – received an updated FDA boxed warning regarding the potential for skin cancer. Because of this warning, their use waned. However, recent data shows these medications are safe to use long term with a low incidence rate and a “small excess risk for individual patients”¹ and the medication’s role to be “unlikely significant.”²

Eczema is not only a disease I help my patients manage; I also deal with it. I am glad to have expanded options to treat this common condition and am encouraged that even more options are on the horizon.

Dr. Jochen is a board-certified dermatologist and the founder of Contour Dermatology & Cosmetic Surgery Center with offices in Palm Springs, Rancho Mirage and La Quinta. He also is a member of Desert Doctors and can be reached at (760) 423-4000 or www.contourderm.com.

References:
1) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856050/;
2) https://www.sciencedirect.com/science/article/abs/pii/S0190962215013560