What to Do When Your OTC Eczema Treatment Isn't Working

For many people with mild eczema, over-the-counter (OTC) lotions and creams are enough to control eczema symptoms. But if your eczema is severe—or it has stopped responding to OTC strategies—you may need a more aggressive therapy.

Determining the Severity of Eczema

When determining the severity of your eczema, your healthcare provider will base it upon characteristics of your skin findings.

With mild eczema, your skin will be dry and may or may not have any redness associated with it. You should also not have any eczema-related disturbances to sleep or other daily activities.

Moderate to moderately-severe cases of eczema may have an impact on your daily activities, including sleep. In cases of moderate eczema, you can expect to have dry, itchy and red areas of eczema. The skin will sometimes also become excoriated.

In severe cases of eczema, you will have widespread areas of dryness and redness. Itchiness increases greatly between moderate and severe cases of eczema. With eczema of this severity, the itchiness that you experience is continuous and can severely impact your ability to sleep and carry on with daily activities. It can affect your mental and social health as well.

Common First-Line Therapies

There are many options available to help treat eczema that can be found over the counter (OTC). Product lines that can be found in your average grocery & home store include:

• Moisturizers (including creams, lotions, balms, ointments, and oils)
• Cleansers (facial and body)
• Laundry detergents and household cleansing agents (to avoid allergens)
• Sunscreens
• OTC medications (Cortizone-10, Cortaid, or Tricalm)
• Skin barrier creams — like Aveeno Eczema Therapy Moisturizing Cream for Sensitive Skin

There are several first-line treatments that you can not buy over-the-counter, but instead can be had with a prescription from your healthcare provider. These products include:

• Topical corticosteroids like Cortizone-10 or other similar products, but in a higher concentration which is why a prescription is required
• Topical PDE4 inhibitors, like Eucrisa
• Topical calcineurin inhibitors, like Protopic or Elidel

Treatment for Severe or Refractory Eczema

If you are suffering from mild to moderate eczema, OTC or some prescription medications are likely all that you will need to treat single or exacerbated occurrences.

A healthcare provider can help evaluate the following common reasons that treatment may initially be ineffective. Reasons can include:

• Non-adherence to medication directions
• The increased presence of environmental triggers (allergens that cause your eczema); this can also include food allergies
• Skin infection - Staphylococcus aureus and herpes simplex virus (HSV) is the most common
• Hypersensitivity or intolerance to the OTC medication
• Incorrect diagnosis - your skin condition isn't actually eczema

Prior to starting any prescription medications to enhance your eczema treatment, the items listed above should all be evaluated to help bring resolution as quickly as possible. A resolution will not occur despite more aggressive therapy if instigating factors have not been removed.

Soak and Smear

If you have eczema that is not clearing up with using OTC medications, the soak-and-smear method may be useful for cases that are widespread.

You start by soaking in a tub of water for 15 minutes. Upon exiting the bath, you apply a high concentrated lotion and apply it to your whole body. If your eczema is isolated to a single limb, you can apply the lotion only to the affected limb.

Wet Wraps

Children, in particular, may benefit from wet wraps if they have failed both topical corticosteroids and/or topical calcineurin inhibitors. Wet wraps consist of three layers:

• First layer - topical ointment directly on the skin
• Second layer - wet bandage soaked in dilute topical steroids
• Third layer - a dry band that goes around the second layer.

Wet wraps can be used for as short a time as 15 minutes to half an hour if done two to three times a day. Typically you will be asked to try and keep these wraps in place for two or more hours, as long as it's tolerated. If possible, you can leave the wet wraps in place for 24 hours if you are able to sleep comfortably with them on.

Wet wraps that are used for more than two hours should be done once or twice a day. Therapy using wet wraps should be used for two to 14 days until symptoms resolve.

Second-Line Therapies

If your eczema has not resolved after 14 days of using wet wraps, and environmental factors have been removed or deemed not applicable, you should seek an evaluation from either an allergist or a dermatologist. They may recommend one or several second-line therapies.

Phototherapy: This treatment is also referred to as light therapy, as it uses narrow-band ultraviolet B rays to treat eczema. Because some cooperation is required, children approximately 6-years old up to adults can receive this therapy.

Treatment usually occurs approximately three times a week and is re-evaluated after approximately 20 to 25 treatments. You should start to see some beneficial effects of phototherapy around the tenth treatment.

When you attend a phototherapy session, plan on applying a moisturizing oil to your entire body and then removing your clothes except for underwear and protective glasses while you are in a booth. The treatment only lasts a few seconds to a few minutes. Your response and dose can be adjusted based on tolerance to the treatment.

Phototherapy is not a quick therapy, as it may take a couple of months to help resolve your eczema. Once resolved, you can either stop phototherapy to determine whether you are in remission, or maintain a maintenance schedule.

Systemic Therapy: This is an additional option that may be considered when other treatments have failed. Systemic treatment involves medications that are considered immunosuppressive, meaning that the medications decrease your body's ability to mount an immune response.

Common medication choices may include:

• Cyclosporine
• Oral corticosteroids (like prednisone)
• Methotrexate
• Azathioprine
• Biologics, such as Dupixent (dipilumab) or Adbry (tralokinumab-Idrm), which are given by injection
• JAK inhibitors, Cibinqo (abrocitinib) and Rinvoq (upadacitinib), taken as a single tablet, once per day

Some of these therapies may require up to eight weeks of treatment. Follow your healthcare provider's recommendations for the length of therapy.

If you require long-term therapy to manage your symptoms, methotrexate and azathioprine are recommended. While both are equally beneficial, you may find that methotrexate is often more tolerable.