Topical steroids have been both extensively used and found to be very effective for the treatment of eczema. Concerns about side effects both on the skin and systemically has increased acceptance of the new steroid free alternative. Worries about long term use of a cortisone cream making the skin less responsive to treatment is a potential risk and is occasionally a concern. This may not occur with the topical immunomodulators but longer term studies will be needed to confirm this.
The new topical immunomodulators (TIMS) provide a significant new choice in the treatment of atopic eczema. They are used as a steroid-sparing medications. There is a discussion whether the immunomodulators should be used alone as monotherapy. Good evidence is available to show that using a potent topical cortisone twice a week only will reduce and may prevent eczema flares. If this was combined with intermittent use the immunomodulators this might further reduce flares. However some TIMs may reduce flares on their own.
For locations such as the face, folds and anterior upper chest the topical immunomodulators seem to be effective, well tolerated and free of significant side effects other than initial and minimal burning.
The following charts simplify some of the anti-inflammatory options:
Long term use of topical corticosteroids can induce tachyphylaxis (tolerance to the vasoconstrictive action of topical corticosteroids). Adverse effects are uncommon when using mild to potent corticosteroids for less than three months, except when used on the face and neck, in intertriginous areas (skin folds), or under occlusion. However, very potent corticosteroids should not be used continuously for longer than three weeks. 2 If longer use of very potent corticosteroids is required, they should be gradually tapered to avoid rebound symptoms and then stopped for a period of at least one week after which treatment can be resumed. 2
There is little evidence as to what percentage of a topical corticosteroid dose is absorbed systemically. Studies investigating systemic effects do not measure how much of the corticosteroid is in the blood, but instead focus on measuring cortisol as a marker of hypothalamic-pituitary-adrenal (HPA) axis suppression. After a few weeks’ treatment with potent or very potent topical corticosteroids temporary HPA axis suppression does occur. However, this resolves upon cessation of the topical corticosteroid, without the need for dose tapering. 5, 19 HPA axis suppression is more marked when topical corticosteroids are applied under occlusion, . with wet wraps.