Treating Severe Eczema: Everything You Need to Know

What is severe eczema?

Your doctor might classify your eczema as mild, moderate, or severe, depending on the intensity of your symptoms. Severe eczema:

• doesn’t respond to standard treatment
• covers a large area of your body
• flares up for longer periods of time

With severe eczema, skin patches may sometimes split and leak fluids. They may also be more prone to infection.

Doctors and their patients can sometimes disagree on what counts as severe. A 2017 study found that doctors and patients disagree on the severity of eczema about 30 percent of the time. Doctors assessed eczema to be more severe than their patients did about 20 percent of the time.

There are tools that people with eczema can use to help determine if their eczema is severe. The Eczema Area and Severity Index (EASI) and Scoring Atopic Dermatitis (SCORAD) tools use a score to describe how severe your symptoms are. Another 2017 study recommended a new system to match scores with the labels of mild, moderate, and severe.

Even if you use one of these tools, it’s best to discuss your symptoms with your doctor. If your eczema is severe, you’ll likely need prescription treatments.

Medications

Corticosteroids

Corticosteroids work by reducing inflammation to relieve itching. High potency and ultra-high potency corticosteroids can be used to treat severe eczema. They shouldn’t be used on sensitive areas, like your neck or genitals, or on large areas of skin.

You can use topical steroids along with wet wraps, which we’ll discuss later on.

Some steroids, like prednisolone or prednisone, can also be taken as a pill. When taken by mouth, steroids go through the whole body. This means that oral steroids can have more significant side effects.

According to a 2021 review, these side effects include:

• weight gain
• muscle weakness
• peptic ulcers
• hypertension
• fluid retention
• mood changes
• cataracts
• insomnia

Oral steroids are usually prescribed to help with severe flare-ups. They should not be taken over a long period of time.

Calcineurin inhibitors

Calcineurin inhibitors are medications that modify your immune system. Their purpose is to reduce the inflammation associated with eczema. Examples of these medications include:

• tacrolimus (Protopic)
• pimecrolimus (Elidel)

These are prescription-only creams that you can apply to your skin. When you use these creams, it’s possible to experience skin irritation, burning, and itching. This will usually go away after a few applications. Other side effects include cold sores or blisters on your skin.

Immunomodulators

Doctors may prescribe oral immunomodulators to people with eczema that isn’t in one specific area. Those who don’t respond to creams may also benefit from taking oral medications. These work by slowing the immune system response, which can help reduce the severity of eczema symptoms.

Examples of immunomodulators for severe eczema symptoms include:

• azathioprine (Imuran)
• cyclosporine
• methotrexate
• mycophenolate mofetil

While these may help to reduce the incidence of eczema, they can come with some severe side effects, including:

• increased risk of infection
• nausea
• high blood pressure
• kidney or liver damage, depending on the medication

As a result, these medications are typically used for a short time to reduce severe symptoms.

Biologics

In March 2017, the Food and Drug Administration (FDA) approved dupilumab (Dupixent). This medication is a biologic that can help lower inflammation in the treatment of moderate-to-severe eczema. It can help those with eczema that isn’t well controlled, as well as people who can’t use topical products.

A second biologic, tralokinumab (Adbry), was approved in December 2022 to treat moderate-to-severe eczema. Your doctor may prescribe that you inject tralokinumab once every two or four weeks.

Trials of each drug involved more than 2,000 adults with eczema over the course of three clinical trials. The trials showed that most people experienced clear skin and reduced itching after about 16 weeks.

Common side effects associated with injectable biologics include:

• conjunctivitis
• cold sores
• eyelid inflammation
• respiratory tract infections
• injection site reactions

Researchers are currently studying other injectable biologics. One such biologic is nemolizumab, which completed phase 2B trials in 2021. Nemolizumab helps lower inflammation and requires monthly injections.

Those in clinical trials for this medication experienced reduced itching. Nemolizumab must undergo more clinical trials before the FDA can approve it for people with severe eczema.

JAK inhibitors

Janus kinases (JAK) send signals that trigger inflammation. JAK inhibitors block these chemical signals.

In January 2022, the FDA approved the first two JAK inhibitors to treat severe eczema:

• abrocitinib (Cibinqo) for adults
• upadacitinib (Rinvoq) for people 12 years and older

Both are once-daily tablets taken if other treatments don’t work for you.

The most common side effects from abrocitinib are:

• nausea
• headache
• acne
• cold sores

The most common side effects of upadacitinib are:

• cough
• nausea
• fever
• upper respiratory tract infection

Another JAK inhibitor, baricitinib, shows promise for treating severe eczema, according to 2021 research. As of 2022, it is still in clinical trials.

Alitretinoin

Your skin needs vitamin A to help repair itself. Alitretinoin (Panretin) is a form of vitamin A and has been shown to be very effective in helping people with hand eczema, according to 2015 research. It is available by prescription only.

Alitretinoin is available in the United States as a topical gel. An oral version available in Europe and Canada has not yet been made available in the United States.

Barrier repair moisturizers

Barrier repair moisturizers help your skin keep in water and repair damage. Some can be purchased over the counter, but others are available by prescription only.

Unlike regular moisturizers, they contain active ingredients that help repair skin with eczema. Some commonly used moisturizers can actually cause further harm to skin affected by eczema, according to 2018 research.

Choosing an appropriate barrier repair moisturizer that works best for you is important, so check with your doctor.

For best results, the National Eczema Association recommends moisturizing after a bath or shower.

Wet wrapping

Wet wrapping is an effective method to treat severe eczema and reduce symptoms in several hours to days.

While wet wraps may sound simple, a doctor or nurse may need to apply them. They’ll spread a corticosteroid cream on the affected area and cover it with a wet bandage. The wet bandages are then covered with dry bandages.

Sometimes, a doctor can show you how to apply the wet wraps so you can put them on at home.

The warm, damp environment under the wrap is ideal for bacteria or fungi to spread. It’s important to check for signs of infection before wrapping.

According to a 2015 review, the most common infections reported as side effects of wet wraps include:

• folliculitis, an infection of hair follicles
• boils
• impetigo, a common skin infection
• pseudomonas infections
• herpes

Other reported side effects include:

• shivering
• itching
• abdominal pain
• diarrhea

Phototherapy

Phototherapy is often used to treat severe eczema that doesn’t respond to creams or covers a wide area. This involves a machine that exposes your skin to ultraviolet (UV) light. The UV light hinders your skin’s inflammatory response.

UVB light is most common. However, some forms of eczema therapy use UVA. Your doctor may give you the drug psoralen to help make your skin more sensitive to UV light two hours before exposing you to UVA rays. This is called psoralen plus ultraviolet A (PUVA) therapy.

This isn’t the same as using a tanning bed, according to the American Academy of Dermatology Association (AAD). Unlike tanning beds, phototherapy is:

• safe for children
• approved by the FDA
• monitored by a dermatologist

Phototherapy usually involves a visit to a dermatologist’s office two to six times a week. Your doctor may reduce the frequency of treatment if it’s effective. It can sometimes take 1 to 2 months for the treatment to take effect.

Side effects of phototherapy are minimal. They may be worse 8 hours after treatment but then improve.

These side effects include:

• itching
• skin dryness
• skin discoloration
• acne

Bleach baths

Bleach baths involve adding a small amount of bleach to your bathwater. The bath helps to moisturize your skin, while the bleach can kill infections like staph infections.

You should talk with your dermatologist before using bleach baths as therapy for your severe eczema. Your doctor will advise you about how often you should take one and how much bleach to use.

According to the AAD, the typical steps are:

1. Measure the amount of bleach you want to use. Use no more than a half-cup for a full standard tub. Adjust for how full you want to make the bath and the size of the bather.
2. Start filling your tub with water. Ensure it’s not too hot or too cold.
3. Add regular strength (5 to 6 percent) bleach to the water as the tub is filling.
4. Soak in the tub for about 5 to 10 minutes.
5. Rinse with warm water.
6. Immediately apply any regular medication or moisturizer to your skin.

Studies have come up with different results about how effective bleach baths are. A 2017 review found that, in most studies, people with eczema found bleach baths to help them with their symptoms. Still, there wasn’t much evidence to support that bleach baths provided better relief than regular water baths.

The National Eczema Association also suggests adding the following to baths to help with symptoms:

• unscented bath oil, to help moisturize your skin
• baking soda, to relieve itching
• oatmeal, to relieve itching
• salt, to ease the sting you might feel from water during a flare
• vinegar, to kill bacteria

If taking a bleach bath, it’s important not to add anything other than bleach to the water.

Additional tips

Managing your severe eczema might have a lot to do with avoiding flare-ups. While you can’t always avoid flare-ups, there are things you can do to reduce your chances of them happening.

Here are some tips to help prevent flare-ups:

• Know your triggers. Avoiding triggers is the best way to prevent flare-ups. Everyone has different triggers, so it’s important to know yours.
• Keep your skin moisturized. Dry skin can cause flare-ups. Be sure to keep up with your regular skin care routines. Avoid water that’s too hot, since it can cause your skin to dry up.
• Avoid scratching. Patches can be unbearably itchy. If you scratch, you might risk tearing the skin and opening it up to infection. Keep your fingernails short and smooth to prevent harmful scratching.
• Use a humidifier. This helps to keep the air in your living or working environment moist. This can help prevent your skin from drying.
• Watch what you eat. Some foods act as triggers as well, but these vary from person to person. Talk with your doctor about a diet that can help you with your severe eczema.
• Wear loose, breathable clothes. Cotton is a natural fabric that is good for skin with eczema. Avoid wool and synthetic fabrics. Be sure to wash new clothes before you wear them.
• Keep a towel with you while you work out. Sweat can dry and irritate skin with eczema. Wipe off sweat regularly when you exercise.
• Find ways to control your stress. Stress and anxiety can be triggers for your eczema, which can then cause greater stress. Try yoga, meditation, or other techniques to keep your stress level down.
• Quit smoking. According to 2016 research, smoke from tobacco products can be a skin irritant, particularly for your hands.

Takeaway

Severe eczema can impact your quality of life. If the itching, burning, and discomfort have made your eczema unbearable, it’s time to contact your dermatologist. You can book an appointment with a dermatologist in your area using our Healinggeeks FindCare tool.

Many medications and therapies are available that can reduce or stop severe symptoms.