Which skin creams are most effective for eczema?
Quelling the discomfort of atopic dermatitis, the most common form of eczema, can be a daily quest. This inflamed, itchy skin condition can interfere with sleeping, socializing, and many other activities.
If home remedies such as gentle cleansing and regular moisturizing don’t provide relief, your doctor might recommend a prescription treatment to apply to your skin. Which prescription cream is most effective? A new study boils it down to a few overall winners.
What is atopic dermatitis and the itch-scratch cycle?
Atopic dermatitis is a chronic inflammatory skin disease. The areas commonly affected include the face, hands, feet, or the skin folds of the elbows or behind the knees.
We don’t know exactly what causes atopic dermatitis. Genes, the environment, and an overactive immune system all seem to play a role in creating inflammation, which feels itchy. Scratching the itch creates more irritation and inflammation, which causes more itching.
As the itch-scratch cycle continues, the rash gets worse. The skin might tear, ooze, and crust over, which can be painful.
Which skin treatments were more effective in the study?
Some prescription topical skin treatments for atopic dermatitis are more effective than others, according to a 2023 study published online by The Journal of Allergy and Clinical Immunology.
Scientists evaluated more than 200 randomized trials involving more than 43,000 people with atopic dermatitis (average age 18). The researchers compared almost 70 different prescription creams or ointments, which are broadly called topical treatments and are designed to be applied to affected areas of skin.
These treatments fall into five categories. If you have eczema, their generic names may or may not be familiar to you, but your medical team is likely to know them well:
- topical corticosteroids, divided into seven classes ranging from the most to the least potent, decrease the release of an inflammatory chemical called phospholipase A2
- topical Janus kinase (JAK) inhibitors interrupt inflammatory signals as they enter cells
- topical PDE4 inhibitors raise the production of a chemical called phosphodiesterase-4, or PDE4, and lower the body’s inflammatory response
- topical calcineurin inhibitors help suppress the production of chemical messengers that tell the body to ramp up its defenses
- other topical treatments, including antibiotics and prescription moisturizers.
Researchers looked at which medications had outcomes important to patients, including which
- were best at improving quality of life
- were best at reducing eczema-related severity, itch, sleep disturbances, or flare-ups
- caused the fewest serious side effects
- were discontinued least often due to serious side effects.
Which atopic dermatitis medications proved to be most effective?
The study yielded some predictable results and a surprise. The overall winners were
- two calcineurin inhibitors: pimecrolimus (Elidel) and tacrolimus (Protopic)
- moderate-potency topical corticosteroids, a large group that includes fluocinolone acetonide (Synalar cream 0.025%) and triamcinolone acetonide (Kenalog cream/ointment 0.1%).
What did these medications improve?
- Pimecrolimus improved six of seven outcomes, and was among the best at reducing sleep disturbances and eczema flares.
- High-dose tacrolimus (0.1%) improved five outcomes, and was among the best at reducing itch and eczema flares.
- Moderate-potency steroids improved four to six of the seven outcomes, and were best at reducing eczema itch, flares, and serious side effects.
“That’s in line with what we often prescribe,” says Dr. Connie Shi, a dermatologist who often treats people with eczema at Harvard-affiliated Brigham and Women’s Hospital. “The strongest topical steroids appeared to be the most effective at reducing eczema severity in the study. However, for longer-term maintenance we may consider switching to a moderate-potency steroid, or one of the nonsteroid options, to minimize the risk of thinning the skin, which can occur with long-term use of topical steroids.”
The surprise finding: the study found little to no effectiveness from using a topical cream twice daily versus just once daily. “The traditional advice is twice daily,” Dr. Shi says. “Once a day would make it more convenient to use, and it may help people stay on their medication regimen without decreasing effectiveness.”
Which treatments were less effective in this study? The researchers found that topical antibiotics were among the least effective treatments for eczema.
Should you change your treatment?
“While the study included more than 40,000 people, what worked for participants may not always work for you, as different people may respond differently to the same treatment,” Dr. Shi explains. “There are many factors to consider when prescribing a treatment, including your age, the areas on your skin that are affected, the severity of the eczema, and potential side effects.”
The bottom line? “If a treatment regimen is working for you, then continue it, as long as you don’t have any serious side effects,” she says. “If your current regimen isn’t working well, talk with your doctor or a dermatologist to see if there’s another prescription cream or ointment that you may want to try.”
About the Author
Heidi Godman, Executive Editor, Harvard Health Letter
Heidi Godman is the executive editor of the Harvard Health Letter. Before coming to the Health Letter, she was an award-winning television news anchor and medical reporter for 25 years. Heidi was named a journalism fellow … See Full Bio View all posts by Heidi Godman
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing
Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD
Want to stop harmful drinking? AA versus SMART Recovery
Ready to address excessive drinking in your life? Many people find peer support helps them take steps toward recovery. Two well-known self-help organizations built around peer support are Alcoholics Anonymous (AA) and Self-Management and Recovery Training (SMART Recovery). While some people seeking recovery even attend both programs, others forego both options.
Why do people choose those different paths — and what do they like, dislike, and find helpful about their chosen option? To find out, researchers questioned 80 participants enrolled in a two-year study about recovery from alcohol use disorder (20 each in AA, SMART Recovery, both, or neither).
Dr. John F. Kelly, professor of psychiatry in addiction medicine at Harvard Medical School, led the study, which was published in the Journal of Substance Use and Addiction Treatment. Here he explains key findings and shares his perspective and advice for people seeking peer support to stop problematic drinking.
Camaraderie: A common theme for both groups
The most striking finding was that for people attending either group, camaraderie was by far the most important aspect.
“There’s something about the connection with other people with similar experiences that helps decrease the self-stigma and shame that people have around this issue,” says Dr. Kelly, who founded the Recovery Research Institute at Massachusetts General Hospital. “Seeing role models of people who found solutions and a way out, and championing these examples of successful recovery, is very powerful,” he adds.
What else do people appreciate about AA?
Founded in 1935, AA has been around far longer than SMART Recovery, which began in 1990. AA’s popularity makes it easy to find meetings, which was one benefit cited in the study. “Within a 45-minute drive of downtown Boston, there are 1,800 AA meetings a week, compared with just 30 SMART meetings,” says Dr. Kelly.
You can also find a wider variety of specialized AA meetings, including those catering to different age groups, women, or LGBTQ+ people, for example. Larger metropolitan areas may have meetings conducted in different languages, as well.
AA follows a 12-step program, defined as a set of spiritual principles that help people achieve sobriety. Yet hardly anyone in the study mentioned spirituality in their responses, says Dr. Kelly. In fact, other research suggests that about half the people attending AA don’t seem to have a strong sense of needing to believe in a formal deity or higher power. “Some people say that connection with other people is what makes it a spiritual experience,” he says.
What else draws people to SMART Recovery?
The study results confirm years of anecdotal reports about why people choose SMART Recovery over AA, says Dr. Kelly. “What attracts people to SMART Recovery is the organization’s focus on science and clinical evidence,” he says.
Their approach incorporates cognitive behavioral therapy (CBT) and motivational psychology into their support groups. The goal is to help participants to recognize and cope with the emotional and environmental triggers for their drinking. Still, in this study, people who chose SMART Recovery stayed with it for the social aspects, according to responses about what they like best about the program, says Dr. Kelly.
Compared to people who attended AA, study participants who chose SMART tended to have less severe problems with alcohol use. They had more education, higher rates of employment, and greater economic resources. They were also less likely to have had prior treatment or involvement with the criminal justice system. SMART may be a particularly good fit for people with that kind of profile.
People who attended both AA and SMART Recovery groups tended to be the most severely affected by their problems with alcohol, and were seeking anything and everything to get help. Those who attended neither program were less seriously affected.
What are other differences between AA and SMART Recovery?
While AA groups are led by members in recovery, SMART groups are led by trained facilitators who are not required to be in recovery themselves.
In the study, that lack of “lived experience” wasn’t perceived as a negative, although some people mentioned that they didn’t like some of the facilitators, Dr. Kelly says. However, a trained facilitator can gently stop and redirect members who engage in meandering, lengthy, and potentially irritating monologues (known as a “drunkalogue”) that may dominate group discussions. AA group leaders don’t intervene in that way and have no formal group facilitation training.
However, AA strongly encourages people who join the fellowship, as it is called, to have a sponsor. Sponsors are experienced members with at least one year of recovery who serve as mentors for new members and are available between meetings. SMART Recovery doesn’t have formal sponsors, but facilitators encourage people to swap phone numbers and reach out to each other between meetings.
Should you participate in a support group to stop drinking?
“When I’m counseling patients, I lay out the different options and let people decide which program seems like the best personal fit for them,” says Dr. Kelly.
Because AA has been around for much longer, he notes that there’s more evidence about what contributes most to success with this approach. Research shows the three factors that have the biggest positive effect on remission for alcohol misuse are:
- Having a sponsor. This is the single most important factor influencing recovery.
- Attending at least three meetings per week. Consistently showing up, especially during the first year, also appears to boost the odds of recovery.
- Speaking at meetings. Saying something aloud in the group meetings — even if it’s just a sentence or two — reinforces the likelihood of ongoing recovery. It also makes it easier to connect with other members in the “meeting after the meeting.”
About the Author
Julie Corliss, Executive Editor, Harvard Heart Letter
Julie Corliss is the executive editor of the Harvard Heart Letter. Before working at Harvard, she was a medical writer and editor at HealthNews, a consumer newsletter affiliated with The New England Journal of Medicine. She … See Full Bio View all posts by Julie Corliss
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing
Dr. Howard LeWine is a practicing internist at Brigham and Women’s Hospital in Boston, Chief Medical Editor at Harvard Health Publishing, and editor in chief of Harvard Men’s Health Watch. See Full Bio View all posts by Howard E. LeWine, MD