Eczema Treatment in Ankara, Turkey

Eczema treatment is a holistic approach aimed at reducing inflammation, itching, and dryness developing in the skin. The treatment plan is arranged according to the type and severity of the eczema. The main goal is to repair the skin barrier, suppress the inflammatory process, and prevent recurrences. It is a disease that requires long-term follow-up.

Topical treatments constitute the first step in eczema management. Moisturizing creams relieve dryness and irritation by reducing water loss in the skin. In inflamed areas, creams containing corticosteroids or calcineurin inhibitors are used. Regular and correct application ensures the preservation of skin integrity.

Systemic drug treatments are preferred in moderate and severe eczema cases. While antihistamines reduce itching, immune-regulating drugs or biological agents may be used when necessary. Phototherapy is also an effective option in treatment-resistant cases.

Environmental and lifestyle modifications are of great importance in eczema treatment. Reducing contact with allergens, avoiding stress, and adopting appropriate skin cleansing habits prevent flare-ups. Creating a personal care routine under the supervision of a dermatologist makes treatment success permanent.

What Is Eczema?

Eczema is a chronic, inflammatory skin disease characterized by itching, redness, dryness, and sometimes blisters on the skin. Atopic dermatitis is the most common type. Genetic predisposition, immune system irregularities, allergens, stress, and environmental factors can trigger eczema. The disease may flare up and subside from time to time. Treatment is generally carried out with moisturizers, corticosteroid creams, and immune-regulating drugs when necessary.

Why Does Eczema Treatment Require a ‘Multi-Step’ Approach?

The foundation of eczema management is a “gradual” or “stepwise” approach. This means that the same standard treatment is not given to every patient, and the treatment is adjusted according to the person’s current condition, the severity of the disease, and its impact on quality of life.

The process always begins with confirming the diagnosis of eczema and determining its severity. It is evaluated how widespread the eczema is (how much of the body it covers) and how much it affects the patient’s daily life (especially sleep and itching).

The treatment process generally follows these steps.

• First step: Diagnosis and severity assessment.
• Second step: Skin care and education.
• Third step: Topical (cream) treatments.
• Fourth step: Phototherapy (light treatment).
• Fifth step: Systemic (injection or pill) treatments.

If control cannot be achieved with the first step, skin care and education, the second step, cream treatments, is initiated. If the disease still cannot be controlled despite these treatments, the patient’s adherence to treatment (whether the medications are being used correctly and regularly) is first evaluated. Other conditions that may mimic eczema (for example allergic contact eczema) are investigated. If the problem is not due to these, the treatment is moved to the next step, namely phototherapy or systemic medications.

There are two main goals in treatment:

• To quickly extinguish acute flare-ups.
• To prevent new flare-ups from occurring (preventive treatment).

Why Have Eczema Treatments Changed So Rapidly in Recent Years?

Eczema treatment has progressed at a dizzying pace, especially in the last decade, and continues to develop. The reason for this rapid change is that we now understand much more clearly the immune system problems underlying the disease and have developed new “targeted” drugs for them. We no longer see eczema simply as “skin dryness and inflammation,” but as a disorder in the specific signaling pathways of the immune system.

Unlike older treatments, these new agents target only the “key” molecules that cause eczema inflammation, instead of suppressing the immune system in general.

These new-generation treatments include the following.

• New biological drugs (injections).
• Topical (cream) JAK inhibitors.
• Oral (pill) JAK inhibitors.
• Topical (cream) PDE-4 inhibitors.

This has completely changed the treatment algorithm. We now have to compare older systemic treatment options such as phototherapy or traditional immune suppressants with these new and targeted treatments. Treatment choice is now made through a “shared decision-making” process that takes into account the patient’s preferences, risk tolerance, and treatment goals.

The Cornerstone of Eczema Treatment: How Is the Skin Barrier Repaired?

No matter which medication we use in eczema management, the basic treatment step can never be skipped. Basic treatment is the repair of the barrier function, which is the protective shield of the skin, and it directly affects treatment success. This step consists of two main components: avoiding triggers and intensive moisturization.

Why Are Proper Skin Care and Avoiding Triggers So Important?

Optimization of treatment begins with educating the patient. The person needs to know what triggers their own eczema and avoid these as much as possible.

Some common triggers include:

• Stress.
• Allergens (pollen, house dust mites, animal dander).
• Certain foods (different for everyone).
• Wool or synthetic clothing.
• Harsh chemicals (detergents, soaps).
• Excessively hot or cold weather.
• Sweating.
• The basic skin care routine should include the following.
• Using soap-free (syndet) cleansers.
• Taking lukewarm and short baths (5-10 minutes).
• Gently drying and moisturizing the skin immediately after bathing (within the first 3 minutes).
• Applying moisturizers generously at least twice a day.

In addition, it is of vital importance to exclude other conditions that may complicate the appearance of eczema or worsen the disease. These include allergic contact eczema, seborrheic dermatitis (oily eczema), psoriasis, and certain immune system disorders:

Are Moisturizers Just a Cosmetic Product, or Are They Considered a ‘Treatment’?

Moisturizers (emollients) should definitely be considered a pharmacological intervention, in other words, part of the treatment.

Their role is not simply to temporarily prevent the skin from drying out. In eczematous skin, the barrier is impaired; think of it as the mortar between the bricks being missing. Moisturizers repair the outermost layer of the skin by providing water and especially “lipid” (fat) supplementation. This “lipid replacement therapy” helps the skin regain its protective function and reduces the underlying inflammation.

Scientific studies have shown that adequate and correct use of moisturizers significantly reduces the need for cortisone cream (TCS). In other words, the better you moisturize and protect your skin barrier, the less medication you will need.

Is Every Moisturizer the Same for Eczema?

There are important nuances in choosing a moisturizer. Common ingredients such as petroleum jelly, mineral oil, and silicone temporarily cover the skin like a film, providing short-term barrier repair and preventing water loss. These are “occlusive” products and they are beneficial.

However, they may be insufficient to permanently correct the underlying defective barrier structure in eczema. For this reason, choosing products containing “physiological lipids” naturally found in the skin (for example ceramides, cholesterol, fatty acids) may help not only to “patch” the barrier but also to repair it fundamentally. The best moisturizer is the one the person’s skin tolerates, does not avoid using regularly, and finds effective.

Which Creams Are Used to Control Flare-Ups?

When basic care and moisturization are not sufficient or when eczema flares up, topically applied immune-regulating (immunomodulatory) creams, which are the second step of treatment, come into play. These creams are used to quickly bring flare-ups under control.

How Do Cortisone Creams (TCS) Work and How Are They Used Safely?

Topical corticosteroids (TCS), in other words cortisone creams, have been the cornerstone of eczema treatment for decades and are still among the most effective and fastest-acting weapons. These creams strongly suppress the inflammatory reaction in the skin.

These creams have a potency classification called “potency”:

• Very strong (Class I).
• Strong.
• Moderately strong.
• Weak (Class VII – for example Hydrocortisone).

The choice of which strength of cream to use is carefully determined according to the severity of the lesion, the anatomical region where it is located (for example weak on the face, strong on the palms), and the age of the patient. In moderate to severe cases, treatment is generally started with a medium- to high-potency cream.

Should Cortisone Creams Be Applied Once a Day or Twice a Day?

This is one of the most frequently asked questions by these patients. Comprehensive scientific reviews have shown that applying cortisone creams once a day (QD) is equivalent in effectiveness to applying them twice a day (BID). In other words, applying them more frequently generally does not bring a better result, but it may increase the risk of side effects. What is important is choosing the correct strength and applying a sufficient amount.

What Is ‘Proactive Treatment’ to Prevent Recurrence After Eczema Has Healed?

Suddenly stopping treatment after an acute flare-up has been controlled and the skin has improved may cause eczema to return quickly (relapse). To prevent this, a protective strategy called “proactive maintenance treatment” is recommended. In this approach, moderately strong cortisone creams are applied intermittently only twice a week (for example on Saturdays and Sundays) to previously problematic areas as a maintenance treatment. This helps the skin remain calm.

Is the Risk of ‘Skin Thinning’ from Cortisone Creams Really High?

The greatest concern regarding cortisone creams is the risk of skin thinning (atrophy). This risk is real, but it is not as common as feared. It may occur especially when strong formulations are used uncontrollably for a long time on the face or in skin folds. However, when the correct potency is chosen, used for the correct duration (generally 1-2 weeks), and proactive treatment is started under physician supervision, the incidence of this side effect is extremely rare.

What Are Non-Cortisone Creams (TCI) and When Are They Preferred?

Topical Calcineurin Inhibitors (TCI) are cortisone-free, anti-inflammatory creams. There are two active ingredients in this group:

• Tacrolimus (%0.03, %0.1).
• Pimecrolimus (%1).

These drugs suppress the activation of immune system cells (T cells) through a different pathway. In this way, they reduce both eczema inflammation and itching. Tacrolimus is approved for moderate to severe eczema, while Pimecrolimus is approved for mild to moderate eczema.

Which Creams Are Safe for Sensitive Areas Such as the Face, Eyelids, and Neck?

This is where the TCI group stands out the most. Areas such as the face, neck, eyelids, and skin folds (armpits, groin) are very sensitive to the risk of thinning caused by long-term use of cortisone creams. TCIs are ideal for these areas because they do not carry a risk of “atrophy” (skin thinning). They can be used safely both for short-term flare-up treatment and for long-term proactive maintenance therapy to prevent recurrences. Their most common side effects are a temporary burning and stinging sensation on the skin when treatment is first started; this sensation usually decreases within a few days.

What Are the Newest Cortisone-Free Creams in Eczema Treatment?

In recent years, creams with entirely new mechanisms of action that do not belong to the cortisone or TCI group have also entered treatment guidelines with strong recommendations.

These new-generation cortisone-free creams are:

• Roflumilast (PDE-4 inhibitor).
• Crisaborole (PDE-4 inhibitor).
• Ruxolitinib (JAK inhibitor).

PDE-4 inhibitors (Roflumilast, Crisaborole) are cortisone-free, powerful options that suppress inflammatory signals and help repair the skin barrier. Roflumilast in particular attracts attention with its suitability for long-term use.

What Does the ‘Black Box’ Warning for Topical JAK Inhibitors (Ruxolitinib) Mean?

Ruxolitinib cream is a topical JAK inhibitor that has received strong recommendations in eczema treatment. JAK (Janus Kinase) enzymes play a key role in the transmission of inflammatory signals within the cell; this cream rapidly reduces itching and redness by blocking this signaling pathway.

However, there is a very important safety note regarding this cream: Topical Ruxolitinib has been approved with the same “black box” warning that highlights the risks associated with oral JAK inhibitors, such as serious infections, cancer risk, cardiovascular problems, and vascular occlusion. Although systemic absorption of these drugs in cream form is very low, their use requires careful evaluation and patient selection because of these potential risks.

Which Treatments Are Used When Creams Are Not Enough?

In patients with widespread and severe eczema who do not respond adequately to cream treatments, light therapy, or other conventional systemic agents, it is necessary to escalate treatment to the third step, namely systemic treatments. These treatments affect the whole body and come in the form of oral pills or injections.

How Do Biological Agents (Injections) Treat Eczema?

Biological drugs have revolutionized the treatment of eczema. These are laboratory-produced proteins that block, with pinpoint precision, the specific cytokine (signal molecule) pathways in the immune system that directly cause eczema inflammation. Unlike traditional immune suppressants, they do not suppress the entire immune system; they target only the source of the problem.

The main drugs in this group are:

• Dupilumab.
• Tralokinumab.
• Lebrikizumab.

These drugs block signals such as IL-4 and IL-13, which underlie eczema. Dupilumab is the agent with the most long-term safety and efficacy data and has been approved even for children older than 6 months. The others target IL-13 more selectively and are approved for those over the age of 12.

What Are the Oral ‘Smart Drugs’ (JAK Inhibitors)?

Janus Kinase (JAK) inhibitors are “small molecule” pills that block the JAK pathways responsible for transmitting inflammatory signals within the cell. They have stood out in the treatment of moderate to severe eczema, especially with their ability to provide a very rapid response.

The main approved agents in this group are:

• Abrocitinib.
• Baricitinib.
• Upadacitinib.

Their most notable clinical effect is that they are extraordinarily effective in providing short-term symptomatic relief, especially itch control. Some patients report that their itching decreases even within 24 hours after taking the medication.

Biological Agent or JAK Inhibitor? According to What Is the Treatment Chosen?

The decision to switch to systemic treatment in moderate to severe eczema is a critical one that balances the urgency of the clinical need, the safety profile of the medication, and the patient’s existing comorbidities.

• Biological Agents (Injections) are approved in a much wider age range (from 6 months onward), and their long-term safety data are much more established. Their effects begin slowly (it may take several weeks), but they are lasting and very safe. They are generally the first preferred systemic agents.
• Oral JAK Inhibitors (Pills), with their rapid and powerful clinical effectiveness, especially the very fast control they provide over itching, are attractive for patients whose symptoms need urgent relief and whose quality of life is very low. However, this speed comes at the cost of stricter monitoring protocols and potential serious safety risks.

This difference requires a clinician to carefully manage, together with the patient, the balance between “slower but safer” biologics and “faster but requiring stricter monitoring” JAK inhibitors.

What Are the Risks of Oral JAK Inhibitors and Why Do They Have a ‘Black Box’ Warning?

The use of oral JAK inhibitors is associated with serious risks that have led to the placement of a “black box” warning for this class of agents. This is the highest level safety warning for a drug and indicates that these drugs should only be considered when other treatments have failed or are not appropriate.

This ‘black box’ warning includes the following serious risks:

• Serious and sometimes fatal infections.
• Herpes Zoster reactivation.
• Cancer (Malignancy – especially lymphoma and skin cancers).
• Venous thromboembolism (VTE – blood clots in veins).
• Major adverse cardiovascular events (MACE – serious heart and vascular problems; heart attack, stroke).

Because of these risks, these drugs should be used very cautiously or not used at all, especially in patients over the age of 65, smokers, those at risk for cardiovascular disease, or those with a history of blood clots or cancer.

Which Evaluations Should Be Performed Before Starting JAK Inhibitor Treatment?

Before starting these drugs and during treatment, it is mandatory to perform a comprehensive risk assessment and screening.

The mandatory screenings before starting treatment are:

• Chest X-ray.
• Latent tuberculosis screening.
• Viral hepatitis (Hepatitis B, C) screening.
• Comprehensive blood count.
• Liver and kidney function tests.
• Lipid (cholesterol) profile.

Which Blood Tests Are Required During Treatment and How Often?

Periodic laboratory monitoring is mandatory to ensure the safety of patients using JAK inhibitors. The tests followed at regular intervals after treatment begins (for example at the 1st month, 3rd month, and periodically thereafter) are:

• Complete Blood Count (to monitor decreases in blood cells).
• Liver Enzymes (to monitor liver toxicity).
• Lipid (Cholesterol) Profile (to monitor cardiovascular risk).

Because of these risks, these treatments are managed only by dermatologists experienced in this area and generally in consultation with other departments such as cardiology and pulmonary medicine.

Is Phototherapy (Light Treatment) Still a Valid Option for Eczema?

Yes, phototherapy, especially the Narrowband UVB (NB-UVB) modality, is recommended as an effective and safe treatment option for patients with chronic moderate to severe eczema.

NB-UVB (Narrowband UVB) is the most frequently preferred technique because of its effectiveness, good tolerability, and low risk. It works by suppressing inflammatory cells in the skin. It is generally applied 2-3 times a week, in total courses of 2-3 months.

Phototherapy continues to exist in clinical practice as an important “bridge treatment” for patients who do not want to take the serious risks of systemic immune suppressants or new JAK inhibitors, or who are not suitable for these treatments.

What Is ‘Wet Wrap’ Treatment for Severe Eczema Flare-Ups?

Wet Wrap Therapy is a very effective method that can be applied in the hospital or at home and is indicated in cases of severe eczema flare-ups, uncontrollable intense itching, and pain.

This technique involves first applying a moisturizer (emollient) or prescribed topical medication (usually cortisone cream) to the skin, then placing cloths moistened with lukewarm water over the affected skin and covering them with a dry layer:

Wet wraps provide an immediate anti-itch effect by cooling the skin through evaporation. They deeply moisturize the skin and help the applied topical medications penetrate the skin much more effectively. In one study conducted in children with severe eczema, it was reported that a reduction of over 70% in symptoms was achieved.

What Is Eczema Herpeticum and Why Is It an Emergency?

Eczema Herpeticum (EH) is an urgent dermatological condition characterized by the widespread infection of damaged atopic dermatitis skin by the Herpes Simplex Virus (usually the cold sore virus).

The diagnosis is made by the presence of sudden-onset, painful, grouped blisters (vesicles) and erosions that appear “punched-out.” Fever and fatigue may accompany it. If left untreated, it may spread and become dangerous.

The treatment protocol is as follows.

• Systemic antiviral (cold sore medication) is started immediately upon suspicion.
• Test results are not awaited.
• Oral pills are used in mild cases.
• In severe cases or when eye involvement is suspected, hospitalization and intravenous medication are required.
• Cortisone creams are paused during the acute infection.

When Should Antibiotics Be Used If Infection Develops on Eczematous Skin?

Colonization of the skin by Staphylococcus aureus (Staphylococcus) bacteria is very common in patients with eczema. However, this does not always mean there is an infection. In order to prevent the development of antibiotic resistance, the use of oral antibiotics has been restricted very strictly.

Antibiotics are used only if there are clear signs of infection. These signs are:

• Purulent (inflammatory) discharge.
• Dense honey-colored yellow crusting.
• Increasing redness, warmth, and pain.
• Fever.

Unless there is obvious evidence of infection, the use of oral antibiotics solely to treat eczema is definitely not recommended. Eczema is primarily an inflammatory disease, not an infectious one.

What Does ‘Decolonization’ Mean for Recurrent Skin Infections?

In patients with a history of recurrent severe infections, decolonization protocols to remove S. aureus (especially MRSA) bacteria from the skin and nose may be applied. This generally involves applying a special antibiotic ointment (Mupirocin) to the nostrils for 5-7 days and bathing with antiseptic solutions (such as Chlorhexidine):

However, it should not be forgotten that these interventions will probably fail if the patient has active, flaring eczema. Therefore, the underlying eczema must first be treated.