Eczema Treatment: Steroids, Biologics, Natural Options

Dermatologists recommend that children and adults on dupilumab (Dupixent) keep applying a fragrance-free, ceramide-containing moisturizer, such as a CeraVe cream or ointment, once or twice daily, because dupilumab calms type 2 inflammation but does not rebuild the skin barrier by itself. In the phase 3 dupilumab trials (Simpson et al., NEJM 2016), patients applied moisturizer twice daily alongside the injections, and US guidelines from the American Academy of Dermatology and the AAAAI/ACAAI Joint Task Force place moisturizers at the base of every step of eczema treatment [7] [10] [11].

The Treatment Ladder

Eczema (atopic dermatitis, often shortened to AD) treatment follows a stepwise approach based on severity. The critical point most patients miss: the foundation (moisturizing, trigger avoidance, and skin care routine) must be in place at every severity level. Adding medications on top of a broken skin care foundation produces poor results [1].

The ladder runs from emollients and gentle bathing, to topical anti-inflammatory creams, to narrowband UVB phototherapy, to systemic medicines such as biologics and oral JAK inhibitors. Each step adds to the one below it rather than replacing it. The eczema treatment guide summarizes the same options by mechanism, and the atopic dermatitis condition overview covers causes and diagnosis.

Step 1: Skin Care Foundation (All Patients)

Moisturizers (Emollients)

The single most important intervention for eczema. Eczema skin has a defective skin barrier (often involving filaggrin gene mutations) that allows transepidermal water loss and allergen/irritant penetration. Daily moisturizing restores barrier function [2].

Choosing the right moisturizer:

• Ointments (petroleum jelly, Aquaphor): Most occlusive, best barrier repair. Greasy feel limits daytime use for some patients. Best applied at night.
• Creams (CeraVe, Vanicream, Cetaphil): Good balance of efficacy and cosmetic acceptability. Look for ceramides, which directly restore the lipid bilayer.
• Lotions: Least occlusive, evaporate quickly. Insufficient for active eczema. Fine for very mild or inactive disease.

Application protocol: apply within 3 minutes of bathing (on damp skin) to lock in moisture. Full body, at least once daily. Twice daily on active areas. Use liberally: a child needs 250 g/week, an adult needs 500 g/week for full coverage.

The Cochrane review by van Zuuren and colleagues (2017) found that moisturizers on their own lengthen the time to a flare and reduce the amount of topical corticosteroid needed [2]. The review did not find a single ingredient or product that clearly outperformed the others, which is why dermatologists usually recommend the plain, fragrance-free product a family will actually use every day.

Bathing Practices

• Lukewarm water (not hot), 5-10 minutes
• Fragrance-free, soap-free cleanser only on dirty areas (groin, axillae, feet). Avoid cleansing eczema-prone areas unless actually soiled.
• Pat dry gently, do not rub
• Apply moisturizer immediately
• Bleach baths (quarter cup regular bleach in a full bathtub, 2x/week) reduce Staphylococcus aureus colonization, which triggers flares in 90% of eczema patients [3]

Trigger Avoidance

• Fragrance-free everything: detergent, soap, lotion, dryer sheets
• Cotton or bamboo clothing (avoid wool and synthetic fabrics against skin)
• Temperature regulation: overheating and sweating trigger flares
• Dust mite reduction if sensitized: encased pillows and mattress, hot-water washing of bedding

Common triggers differ from person to person, and food is a trigger far less often than families expect. The guide to common eczema triggers covers irritants, allergens, sweat and stress in more detail.

Step 2: Topical Anti-Inflammatory Treatment

Topical Corticosteroids (TCS)

The first-line anti-inflammatory for eczema flares. Available in 7 potency classes (Class I strongest, Class VII weakest in the US system). Choosing the right potency for the right location is the key skill [4]:

Addressing steroid phobia: topical corticosteroid side effects (skin thinning, stretch marks, telangiectasia) occur with prolonged continuous use of inappropriate potency on thin-skinned areas. Used correctly (right potency, right location, 2-4 week courses with maintenance), TCS are safe. Undertreatment from steroid fear causes more disease burden than appropriate steroid use [5].

Proactive Maintenance (“Weekend Therapy”)

Instead of waiting for flares and treating reactively, apply mid-potency TCS to previously affected areas 2x/week even when the skin appears clear. This approach reduces relapse rates by 50-70% in clinical trials and is now the standard recommendation for patients with frequently relapsing eczema.

Topical Calcineurin Inhibitors (TCI)

• Tacrolimus 0.03% and 0.1% (Protopic): As effective as medium-potency TCS without atrophy risk. Ideal for face, eyelids, and genital areas for long-term use. Common side effect: burning/stinging on application (resolves after a few days).
• Pimecrolimus 1% (Elidel): Less potent than tacrolimus. Best for mild-to-moderate disease on sensitive areas. Good for maintenance therapy.

Topical PDE4 Inhibitor

• Crisaborole 2% (Eucrisa): A non-steroidal, non-calcineurin inhibitor option for mild-to-moderate eczema. Less effective than medium-potency TCS but offers a steroid-free option. Main side effect: application site stinging.

Topical JAK Inhibitor

• Ruxolitinib 1.5% cream (Opzelura): Approved for mild-to-moderate atopic dermatitis. Anti-itch effect is rapid (within 36 hours). Provides a new mechanism for patients who prefer non-steroidal options. Use limited to 20% BSA and 60 g per cycle due to systemic absorption concerns.

Ruxolitinib cream labeling also advises against using it together with biologics such as dupilumab, other JAK inhibitors or potent immunosuppressants, so it is usually a choice made instead of a systemic medicine rather than on top of one. For more on choosing between these prescription creams, see the eczema cream comparison.

Step 3: Phototherapy

Narrowband UVB (NB-UVB) is effective for moderate-to-severe eczema that is widespread and poorly controlled with topicals alone. Treatment is 2-3 times weekly for 8-12 weeks in a light booth or with a home unit [6].

Mechanism: UVB suppresses T-cell mediated skin inflammation, reduces pruritus, and improves barrier function. It is safe for long-term use and can be combined with topical therapies.

Limitations: requires frequent clinic visits (or a home unit), time-consuming, and not practical for localized disease. Most effective for trunk and limb eczema.

Step 4: Systemic Therapies

Dupilumab (Dupixent)

A monoclonal antibody blocking IL-4 and IL-13, the key type 2 inflammatory cytokines driving eczema. Approved for moderate-to-severe atopic dermatitis in adults and children aged 6 months and older [7].

• EASI-75 (75% improvement) in 44-51% of patients at 16 weeks (vs. 12-15% placebo)
• Dramatic itch reduction (average 50-60% reduction in peak pruritus score)
• Onset of itch relief within 2 weeks; skin improvement over 4-16 weeks
• Self-administered subcutaneous injection every 2 weeks
• Main side effect: conjunctivitis (10-20%), injection site reactions
• No immunosuppressive monitoring required. No increased infection risk.

Dupilumab was a paradigm shift for eczema treatment. For the first time, patients with severe, refractory eczema had an effective, safe, long-term option.

The every-2-weeks schedule above is the adult regimen. Children receive weight-based doses set by the prescriber from the FDA prescribing information, and younger children are often dosed less frequently. Dupilumab was studied with moisturizers in every pivotal trial, and the pediatric trials added topical corticosteroids, so the injections are designed to sit on top of daily skin care rather than replace it [7] [12].

JAK Inhibitors (Oral)

• Abrocitinib (Cibinqo): JAK1 inhibitor. 100-200 mg daily oral. Rapid onset (itch improvement within days). EASI-75 in 44-63%. Risk considerations: herpes zoster, acne, nausea, headache.
• Upadacitinib (Rinvoq): JAK1 inhibitor. 15-30 mg daily oral. EASI-75 in 62-73% (highest clearance rates among current systemic options). Outperformed dupilumab in head-to-head trials for skin clearance, though safety profile is narrower.
• Baricitinib (Olumiant): JAK1/JAK2 inhibitor. 2-4 mg daily. Approved in Europe and some other markets for eczema. Lower efficacy than abrocitinib and upadacitinib.

JAK inhibitors require monitoring: CBC, liver function, lipids, and screening for tuberculosis and hepatitis before starting. Risk of herpes zoster is elevated; vaccination before starting is recommended.

Tralokinumab (Adbry)

An IL-13-specific monoclonal antibody. Subcutaneous injection every 2 weeks. EASI-75 in 25-33% as monotherapy. Less effective than dupilumab in indirect comparisons but may benefit patients who do not respond to or cannot tolerate dupilumab.

Newer Biologics

Two more injectable biologics reached the US market in 2024. Lebrikizumab (Ebglyss) blocks IL-13, like tralokinumab, and nemolizumab (Nemluvio) blocks the IL-31 receptor, a pathway closely tied to itch. Both are approved for adolescents and adults rather than young children, and long-term comparative data against dupilumab are still limited.

How the Systemic Options Compare

The figures below are the ones stated in the sections above. They come from separate trials with different designs, so they show a general range rather than a direct ranking.

Traditional Immunosuppressants

Used less frequently now that biologics and JAK inhibitors are available, but still relevant when access or cost is a barrier:

• Cyclosporine: Rapid onset, effective. Limited to 1-2 years due to nephrotoxicity. Useful as a bridge to biologic therapy.
• Methotrexate: Slow onset (8-12 weeks). Modest efficacy. Lower cost. Weekly dosing.
• Azathioprine: Slow onset. Used when other options fail or are unavailable. TPMT testing required before starting.
• Mycophenolate mofetil: Off-label. Moderately effective. Used as a steroid-sparing agent.

Using CeraVe and Other Moisturizers With Dupilumab

Dermatologists advise continuing a daily moisturizer for the whole course of dupilumab therapy, in children and adults alike. Dupilumab blocks IL-4 and IL-13 signaling from inside the body, while a ceramide cream such as CeraVe works on the outer skin barrier, so the two act on different parts of the disease. There is no known interaction between topical moisturizers and dupilumab.

Do dermatologists recommend moisturizer during dupilumab therapy?

Yes. In SOLO 1 and SOLO 2, the trials that led to dupilumab's approval, participants applied an emollient twice daily before and during treatment, so the published results already include moisturizer use [7]. The American Academy of Dermatology (Sidbury et al., 2023) and the AAAAI/ACAAI Joint Task Force (Chu et al., 2024) both recommend moisturizers for atopic dermatitis regardless of what other treatment a patient receives [10] [11].

Which moisturizer features matter for a child on dupilumab?

Guidelines recommend a category, not a brand. Pediatric dermatologists generally look for these features, which several drugstore lines, CeraVe among them, offer:

• Fragrance-free and dye-free, since fragrance is a common cause of contact allergy in children with eczema.
• A cream or ointment texture rather than a lotion, because thicker products reduce water loss more.
• Ceramides, petrolatum or glycerin as main ingredients to support the lipid barrier.
• No food-derived oils such as peanut oil for infants, given concern about sensitization through broken skin.
• A large tub or pump that makes it practical to apply enough: about 250 g per week for a child.

Evidence that one ceramide product beats another is thin. The Cochrane review found no clear winner among moisturizer types, so the product a child tolerates and the family uses consistently is the right one [2].

A daily routine for a child on dupilumab

1. Give a lukewarm bath of 5 to 10 minutes, using a soap-free cleanser only where skin is soiled.
2. Pat the skin dry and apply moisturizer to the whole body within 3 minutes.
3. On active patches, apply the prescribed topical corticosteroid or calcineurin inhibitor as directed. Practice varies on order: many dermatologists apply the medicated cream to inflamed skin and moisturizer everywhere else, or space the two apart.
4. On injection days, inject into clear skin, not into tender, bruised, damaged or eczema-affected skin, as the prescribing information directs.
5. Reapply moisturizer at bedtime; an ointment works well overnight on very dry areas.
6. Watch the eyes for redness, itching or discharge, and report them early so the care team can arrange an eye assessment.

Which topicals can be combined with dupilumab?

Managing Itch

Pruritus is the most disabling symptom of eczema and the primary driver of the itch-scratch cycle that worsens disease. Beyond anti-inflammatory treatment:

• Keep nails short: Reduces scratch damage
• Cold compresses: Immediate but temporary itch relief through TRPM8 activation
• Oral antihistamines: Sedating antihistamines (hydroxyzine, diphenhydramine) help with nighttime itch through sedation, not direct anti-itch action. Non-sedating antihistamines (cetirizine, loratadine) are not effective for eczema itch.
• Menthol-containing creams (0.5-1%): Topical counter-irritant that provides temporary itch relief

Wet Wrap Therapy

A highly effective technique for breaking severe flare cycles. Protocol [8]:

1. Bathe in lukewarm water for 10 minutes
2. Apply topical corticosteroid (diluted or standard potency, per provider guidance) to affected areas
3. Apply a thick layer of emollient over the entire body
4. Cover with a damp layer of tubular bandage or wet cotton clothing
5. Cover with a dry layer on top
6. Leave on for 2-4 hours (or overnight)

Wet wraps increase topical medication absorption by 10x, provide physical barrier against scratching, cool the skin, and restore hydration. Typically used for 3-7 consecutive days during severe flares.

Wet wraps are often used in children, and they can be used during dupilumab therapy when a flare breaks through. Because the wraps increase absorption, the strength of any steroid under them should come from the treating clinician.

Natural and Complementary Approaches

• Sunflower seed oil: Contains linoleic acid, which supports skin barrier repair. Applied topically, it has shown benefit in neonatal studies. Use as a supplement to (not replacement for) standard emollients.
• Coconut oil: Has antimicrobial properties against S. aureus. A small RCT showed improvement in SCORAD scores versus mineral oil. Safe as a supplemental emollient.
• Evening primrose oil: Contains gamma-linolenic acid (GLA). Oral supplementation studies show mixed results. A 2013 Cochrane review found insufficient evidence to recommend.
• Probiotics: Evidence for prevention (prenatal/early life supplementation reduces eczema risk by 20-30%). Evidence for treatment of established eczema is weaker, with some benefit for Lactobacillus rhamnosus strains [9].
• Vitamin D: Deficiency is common in eczema. Supplementation may reduce winter flare severity, particularly in children.

Integrative and functional medicine clinics also offer approaches such as elimination diets, gut health protocols, red light therapy and IV nutrient infusions for eczema. Evidence for these in atopic dermatitis is limited, most are cash pay, and none replace the moisturizer and anti-inflammatory steps above. The eczema diet guide covers what the food research does and does not show.

When to See a Dermatologist

• Eczema covers more than 10% of body surface area
• Symptoms are not controlled with OTC moisturizers and low-potency steroids
• Sleep is disrupted by itch more than 2 nights per week
• Recurrent skin infections (crusting, weeping, honey-colored drainage) suggest S. aureus infection requiring antibiotics
• Eczema affects the face, hands, or genitals and topicals are not sufficient
• You want to discuss biologic or systemic therapy options

For children, the usual path runs from the pediatrician to a pediatric dermatologist, with an allergist-immunologist involved when food or environmental allergy is suspected. Children on dupilumab who develop persistent eye symptoms are often referred to an ophthalmologist. The guide to eczema in babies covers infant skin care and when to escalate.

Finding Eczema Treatment Near You

Board-certified dermatologists prescribe the topical, phototherapy and systemic treatments described above, and many also manage dupilumab in children. Some patients also look for clinics that pair conventional care with integrative support. The national list of clinics offering eczema treatment can be filtered by state, and each profile lists the services and clinicians at that location.

Listing order on Regenerated.com is not paid ranking. Featured slots are labeled and capped, Verified means a clinic has passed credential checks rather than paid for placement, and the directory is free for patients. Inclusion in the directory is not an endorsement, so confirm credentials and ask how a clinic coordinates with your dermatologist. The guide to Featured, Verified and organic listings explains each label.

Frequently asked questions

Can you use CeraVe while on Dupixent?

Yes. Dermatologists recommend continuing a fragrance-free moisturizer, such as a CeraVe cream or ointment, throughout dupilumab (Dupixent) treatment. There is no known interaction, and the SOLO trials that led to approval had patients apply emollients twice daily alongside the injections. Dupilumab reduces type 2 inflammation, while the moisturizer supports the damaged skin barrier, so the two work together.

Do children on dupilumab still need topical steroids?

Many do, at least for a while. The pediatric dupilumab trials combined the injections with topical corticosteroids, and dermatologists commonly keep a low or medium potency steroid, or tacrolimus for the face, on hand for breakthrough patches. As the skin clears, use usually drops to occasional spot treatment or twice-weekly proactive maintenance. The treating clinician decides the potency, area and duration for each child.

How long does dupilumab take to work for eczema?

Itch usually improves first, often within about 2 weeks of starting dupilumab. Visible skin improvement builds over 4 to 16 weeks, and the main trial results were measured at week 16, when 44 to 51 percent of adults reached EASI-75 compared with 12 to 15 percent on placebo. Daily moisturizing and topical treatment for flares continue during this period, which is why dermatologists judge response after several months rather than weeks.

What side effects should parents watch for on dupilumab?

Eye problems are the most common side effect of dupilumab: conjunctivitis occurred in roughly 10 to 20 percent of trial participants, along with dry or itchy eyes. Injection site reactions are also common. Some patients develop redness on the face and neck during treatment, and the cause is still debated. Report eye symptoms early, because an eye assessment and lubricating or anti-inflammatory drops often allow treatment to continue.

What is the first-line treatment for eczema?

The first-line treatment for eczema is daily moisturizing with a fragrance-free emollient, combined with gentle bathing and trigger avoidance. For flares, topical corticosteroids matched in potency to the body area are the standard first anti-inflammatory step, with tacrolimus or pimecrolimus for the face and skin folds. Phototherapy and systemic medicines such as dupilumab are added for moderate-to-severe eczema that topical treatment does not control.

Can moisturizer be stopped once eczema clears on dupilumab?

Dermatologists generally advise against stopping. Eczema skin keeps an underlying barrier defect, often linked to filaggrin gene changes, even when it looks clear on dupilumab. Continuing a daily moisturizer, and in frequently relapsing cases twice-weekly proactive treatment of old flare sites, reduces the chance of new flares. Many families scale back to once-daily application during clear periods and return to twice daily in winter or during flares.

Related Reading

• Eczema: The Evidence-Based Guide (Pillar)
• Dyshidrotic Eczema: Hand and Foot Blistering Eczema Guide

Sources

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2. van Zuuren EJ, Fedorowicz Z, Christensen R, et al. Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;2(2):CD012119. doi:10.1002/14651858.CD012119.pub2 ↩
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