Atopic dermatitis (eczema) is a chronic inflammatory skin condition that causes intense itching, redness, and discomfort. While topical steroids are often the first line of defense, they aren’t always effective, particularly for long-term management. This article breaks down what happens when steroids fail to control eczema flares and outlines the growing range of alternative treatments now available.
Why Topical Steroids Aren’t Always Enough
Topical steroids can rapidly reduce inflammation during an eczema flare-up. However, prolonged use can thin the skin, making it more vulnerable. Dermatologists generally recommend short-term use only.
The core issue? Eczema is rarely caused by a single factor. It’s often triggered by a combination of genetic predisposition, environmental irritants (like dry air or dust mites), allergies, and even stress. If underlying triggers remain unaddressed, steroids only mask the symptoms, not cure them.
Prescription Topicals Beyond Steroids
When steroids no longer provide relief, dermatologists turn to a variety of non-steroidal prescription topicals:
- Calcineurin Inhibitors (Pimecrolimus, Tacrolimus): These creams suppress the immune response in the skin, reducing inflammation without the long-term side effects of steroids.
- PDE-4 Inhibitors (Crisaborole, Roflumilast): These medications dampen an overactive immune system by blocking an enzyme called PDE4, decreasing itching, swelling, and rashes.
- JAK Inhibitors (Ruxolitinib): These block specific inflammatory signals within the immune system, offering a more targeted approach.
- Aryl Hydrocarbon Receptor Agonists (Tapinarof): These work to repair the skin barrier and reduce inflammation.
These topicals may be used alone or in combination, depending on the severity and frequency of flares.
Systemic Medications: When Skin-Deep Isn’t Enough
For severe cases, systemic medications work throughout the body to reduce inflammation:
- JAK Inhibitors (Abrocitinib, Upadacitinib): Oral JAK inhibitors target inflammatory pathways systemically. While results aren’t immediate, itching often improves quickly.
- Biologics (Dupilumab, Lebrikizumab, Nemolizumab, Tralokinumab): These injectables target specific parts of the immune system, blocking chemical messengers that drive inflammation.
- Immunosuppressants (Cyclosporine, Methotrexate, Azathioprine, Mycophenolate): Older but still effective, these medications broadly suppress the immune system. They are typically reserved for severe cases where other options fail.
Older oral corticosteroids like prednisone are rarely recommended due to significant side effects.
When to Seek Medical Attention
If your usual treatments stop working, it’s time to see a dermatologist. Signs include:
- Intense, constant itching
- Fluid-filled blisters or crusting
- Swelling
- Sleep disturbance due to symptoms
- Increased skin sensitivity
- Widespread rashes
- Fever or warmth around affected areas
Treatment for eczema is iterative. Dermatologists adjust therapy based on symptom control, starting with low-potency options and escalating as needed.
The Bottom Line
Topical steroids are a useful initial treatment for atopic dermatitis, but they aren’t a long-term solution. A growing range of non-steroidal prescription medications—both topical and systemic—offer effective alternatives, often with fewer side effects. Finding the right treatment may require patience and collaboration with a dermatologist.
