Over my 30 years of Dermatology practice, I have treated over 20,000 patients for various forms of dermatitis and eczema. A complaint I often hear from new patients of this type is that prescription creams just “don’t seem to work.” While these patients are not wrong, they aren’t completely right, either. In this article, I will discuss why prescription creams often don’t work like they should, situations they work extremely well for, and my solution for “bridging the gap” between prescription treatments and fully healed skin.
Efficacy Trials: A Double-Edged Sword
It’s important to understand that many prescription corticosteroid products in Dermatology have been developed with the goal of rapid biologic effect in a trial for the FDA. Thoroughly and successfully treating an actual rash or eczema problem is not always in the equation. Observing a powerful and rapid corticosteroid effect on redness or vasodilation is usually the model for the trial. The concept of fully healing the skin and the epidermal barrier was never in the equation, for many approval processes.
In an FDA study, the applicant must show that the drug performs the action designated for its official use. Here’s the issue: prescription steroid creams are often not registered for “healing eczema.” Instead, they are typically for just the treatment of the physical inflammatory rash associated with the condition. The official FDA document for triamcinolone acetonide cream, for example, says that the drug is for the relief of “manifestations of dermatoses”. This distinction is important because it causes the drug formulas to be created in a way that shows maximum effectiveness in the study only for rash relief. As a result, the “vehicle” that the drug is carried in (the base cream, ointment or lotion that carries the active ingredient steroid) often sacrifices actual healing for better study performance.
How Healing Can Be Sacrificed For Results
One way to make a drug formula’s active ingredient perform better is to seek better skin penetration, commonly with a harsh solvent like propylene glycol. A solvent ingredient will increase the penetration of the active ingredient into the skin, but almost never contributes to the skin’s actual “healing progress.” When tested for the FDA, it produces a powerful vasoconstriction or anti-inflammatory effect which helps to show great results at making the rash improve over 50% for the study. However, this response doesn’t necessarily lead to healing and maintenance of healing.
The developer of a prescription product might also have been concerned that a “very healing” cream vehicle might produce confusion in the efficacy studies of the active ingredient. FDA studies are always placebo-controlled. In this situation, the placebo contains everything in the formula’s “vehicle” except for the active ingredient. If the vehicle were to help relieve the rash by itself, it could make the effects of the active ingredient seem less dramatic. As a result, prescription drug formulas almost never contain ingredients that help the healing or recovery process.
Now you may be wondering why drug developers don’t just target “complete healing” in their approval studies. The truth is, complete healing of ANY chronic condition is almost never an endpoint in ANY FDA study. Drugs are typically designed to have 1 mechanism of action, while most chronic conditions, especially eczema, have many issues happening at once. However, while prescription steroids are not designed for complete eczema healing, they still have an important use.
Short Term and Long Term Eczema Treatment Prescriptions
I sometimes prescribe products with propylene glycol for initial periods of treatment, if the patient has no allergy to it. They are excellent for initial control of thick, severe eczema or dermatitis rashes. However, I never use them for the continued overall “healing progress” of the skin. For this, I rely on moisturizers like CeraVe® Cream combined with SmartLotion®, as well as helping to eliminate the factors contributing to harming the skin, or inciting inflammation.
SmartLotion® is designed to counteract the harshness in many prescription dermatology products, without adding side effects. It offers a healing product that can be used (along with proper cleansing and moisturizing) long after the pharmacist has instructed that the prescription product should be discontinued. This is important so that further healing occurs. It can be started before the discontinuation of the prescription product, and overlap. This increases the likelihood of continued “healing progress” when the prescription is discontinued. The patient need not worry about the vehicle in the prescription so much, because the SmartLotion® takes over the healing responsibilities.
Eczema Treatment and the Further Uses of SmartLotion®
In addition to helping prescription strategies to work better, SmartLotion® is a stand-alone product for itching related to inflammation and dermatitis. I use it to directly address and treat seborrheic dermatitis (scientific name for dandruff and pink, scaly spots on the face) by itself. However, a good cleansing of the face and scalp is always a must before application. Beyond seborrheic dermatitis, SmartLotion® is also a great product enhancer, for use with a large number of prescription products for inflammation and immune dysregulation.
Many patients with atopic dermatitis are never going to fully heal and stay in remission when putting a solvent on their skin. Another common problem I see is that they may use a greasy ointment that holds in heat and retains redness. Many providers writing prescriptions do not understand that atopic dermatitis patients will stay red and the barrier functions of their skin will be less likely to fully heal with a greasy ointment. When I find that patients are prescribed a greasy ointment, I often recommend “overlap therapy” and help them to get away from the ointment as soon as they can.
When a dermatitis or psoriasis patient stops or tapers off a prescription product with penetration enhancers, they still have barrier problems and damaged skin. They often have irritating, pro-inflammatory yeast and bacteria living on the surface. When patients taper off SmartLotion®, they have a better-healed skin barrier and microbiome. A gradual taper over a month or two of SmartLotion® is ideal for many of my patients. A taper can mean tapering to once a day with supervision by your dermatologist provider, or a taper to 3 days a week maintenance, or a taper completely off SmartLotion®, but continuing daily moisturizing.
A prescription corticosteroid with a vehicle designed for penetration often doesn’t help patients enough. Particularly when the pharmacist tells them to discontinue use after two weeks. I was able to formulate SmartLotion® with complete healing in mind. It heals the epidermis and its barrier functions, while improving the microbiome with its prebiotic properties. By itself, the microbiome enhancement strategy is healing and anti-inflammatory.
Eczema Treatment Prescription Round-Up
In summary, prescription topical corticosteroids often fail at actually healing eczema because of shortcomings in the base lotion, and from steroid side effects concerns. However, these products are useful for initial control, when used correctly. I created SmartLotion® because it was “the missing step” or the bridge patients needed between prescription products and complete healing for their chronic dermatitis. It helps to provide all the missing tools from the “eczema healing” toolbox in 1 simple, easy-to-use formula. If you haven’t yet, go try it today - and I encourage you to do so with your dermatologist’s supervision.
Steve Harlan, MD FAAD
Board Certified Dermatologist