Effectiveness of Topical Anti-Inflammatory Drugs for Eczema

Which topical anti-inflammatory drugs are most effective for the treatment of eczema (atopic dermatitis)?

Low- to moderate-confidence evidence shows that select topical anti-inflammatory drugs are the most effective treatment for eczema. These potent and very potent drugs include corticosteroids (eg, clobetasol), calcineurin inhibitors (eg, tacrolimus 0.1%), and Janus kinase inhibitors (eg, ruxolitinib 1.5% [Opzelura]). Alternatively, phosphodiesterase 4 (PDE4) inhibitors (eg, crisaborole 2%) are among the least effective. Adverse effects (eg, burning, stinging) are more likely with topical calcineurin inhibitors and PDE4 inhibitors and less likely with topical corticosteroids.¹ (Strength of Recommendation: A, consistent, good-quality, patient-oriented evidence.)

Eczema, also known as atopic dermatitis, is a chronic, pruritic, inflammatory skin condition. Patients often have concomitant allergic rhinitis and asthma.² Although it affects up to 25% of children, prevalence decreases with age; only 7.3% of adults reported eczema symptoms in the 2021 National Health Interview Survey.^2,3 The authors of this Cochrane review investigated the most effective and safest topical anti-inflammatory drugs for eczema.¹

This review included 291 studies and 45,846 patients ranging in age from 1 month to 70 years with eczema of any severity.¹ The authors considered randomized controlled trials comparing various anti-inflammatory treatments, such as topical corticosteroids, topical calcineurin inhibitors, PDE4 inhibitors, Janus kinase inhibitors, and aryl hydrocarbon receptor activators. The protocols and durations of use of the drugs varied. Doses of steroids were not clearly defined, and it was not clear from this analysis how drug potency was delineated. Drug potency, which typically ranges from low to very high, increases as the concentration of corticosteroid increases.⁴

Outcomes included patient-reported eczema symptoms, clinician-reported eczema signs, and reported adverse effects. Most of the studies had both male and female patients. Studies were conducted in several countries, with incomes ranging from lower-middle to high, across six continents.

Across all primary outcomes reported by patients and clinicians, the best anti-inflammatory treatments for eczema are topical corticosteroids, Janus kinase inhibitors, and topical calcineurin inhibitors.¹ Among 40 trials (n = 6,482) using patient-reported symptoms as a binary outcome (ie, symptoms present or absent), low-certainty evidence demonstrated that the most benefit was noted using tacrolimus 0.1% (odds ratio [OR] = 6.27; 95% CI, 1.19–32.98), potent topical corticosteroids (OR = 5.99; 95% CI, 2.83–12.69), and ruxolitinib 1.5% (OR = 5.64; 95% CI, 1.26–25.25). These same drugs were also rated as having the highest effectiveness with moderate confidence in 32 trials (n = 4,121) that examined clinician-reported signs as a binary outcome.

In 29 trials (n = 3,839) using patient-reported symptoms as a continuous outcome, very potent topical corticosteroids (standardized mean difference [SMD] = −1.99; 95% CI, −3.25 to −0.73; low confidence) and tacrolimus 0.03% (SMD = −1.57; 95% CI, –2.42 to −0.72; moderate confidence) were the highest-rated drugs.¹ In 49 trials (n = 5,261) that used clinician-reported signs as a continuous outcome, the same drugs (very potent topical corticosteroids and tacrolimus) were rated the highest.

Regarding local adverse effects, 83 trials (n = 18,992; 2,424 events) reporting application site reactions revealed that tacrolimus 0.1% (OR = 2.2; 95% CI, 1.53–3.17; moderate certainty), crisaborole 2% (OR = 2.12; 95% CI, 1.18–3.81; high certainty), tacrolimus 0.03% (OR = 1.51; 95% CI, 1.10–2.09; low certainty), and pimecrolimus 1% (OR = 1.44; 95% CI, 1.01–2.04; low certainty) were most likely to cause site reactions compared with placebo.¹ Topical corticosteroids were the least likely class to cause site reactions.