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A Comprehensive Guide To Topical Treatments For Atopic Dermatitis

Following a large review of topical treatments for people with atopic dermatitis (AD), investigators determined that pimecrolimus, tacrolimus, and moderate-potency topical corticosteroids (TCS) are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics, meanwhile, were among the least effective.

The systematic review and network meta-analysis included 219 trials, comprising a total of 43,123 patients and 68 separate interventions. As part of the report, published in The Journal of Allergy and Clinical Immunology, investigators created a quick bedside reference guide for decision-making on topical treatments for AD patients.

The report's first author, Derek Chu, MD, PhD, is a dermatologist-researcher and assistant professor of medicine at the McMaster University Faculty of Health Sciences in Canada. His exchange with the Reading Room has been edited for length and clarity.

What were the key drivers behind this review?

Chu: The topical treatments review is critical because, number one, no comprehensive systematic review and network meta-analysis had been done to bring together all the cumulative information to date about eczema and inform patients how treatments fare against each other. There are about 60 different treatments that can be used to treat patients with mild to moderate AD. We need to whittle down this overwhelming number of choices and synthesize what does and doesn't work so that informed decisions can be made.

This review puts everything together into an evidence-based way so that people can make informed decisions.

What were your key findings?

Chu: With high certainty, pimecrolimus improved 6 of 7 outcomes, and low-dose tacrolimus (0.03%) improved five. With moderate-to-high certainty, several TCS improved as many as 6.

Crisaborole and difamilast were intermediately effective, but of uncertain harm. Topical antibiotics alone or in combination may be among the least effective.

There are also emerging treatments such as topical JAK inhibitors. There are different kinds that had a modest effect in improving clinical signs. They did improve other features, such as itch, or quality of life, but ultimately effects were still modest. We have to balance all of these with potential harms of each of the medications, and unfortunately these do have a black box warning.

Please describe the clinical guide you put together as part of this paper.

Chu: I encourage everyone to look in detail about the actual summary table. You can use that as a point of care. You can print it out, you can use it as a poster. It's fully open access and readily available to anyone. It can even be used to guide conversations and help walk patients through what to expect, because it shows improvements in every single outcome.

What is your take-home message for clinicians managing patients with AD?

Chu: This review can change how clinicians might approach eczema care. The summary table is a critical feature to help decide with patients what to do when, and why it's important.

We not only address things like what is the best treatment option available to patients, but also how often do you need to apply the treatment? Do you need to apply twice a day, once a day, something else? And once you gain initial control, how do you keep control?

This is all described in this paper and it's been systematically summarized in a very evidence-based way.

Chu did not disclose any relevant financial relationships with industry. Co-authors report relationships with several companies that are manufacturers or importers of pimecrolimus, tacrolimus, topical steroids, or antibiotics.

Antifungals Are Going The Way Of Antibiotics—overused, Hitting Resistance

Enlarge / Ringworm. CDC/Getty Images reader comments 80

Clinicians in the US may be overprescribing topical antifungal treatments for skin infections, potentially exacerbating a growing problem of drug resistance, according to a new study.

Further Reading Drug-resistant ringworm reported in US for first time; community spread likely Last year, a dermatologist in New York reported the country's first cases of a newly emerging skin fungus that is highly contagious and resistant to common antifungal treatments. Silent community spread appeared to be behind the unconnected cases. Overall, drug-resistant fungal skin infection cases (aka ringworm) have been identified in at least 11 US states to date.

With resistance on the rise, researchers at the Centers for Disease Control and Prevention took a closer look at how US clinicians prescribe topical antifungals. As is the case of antibiotics and bacterial infections, overuse of antifungals can drive the development of resistance. And properly diagnosing skin infections can be extremely difficult without diagnostics. A 2016 survey study found that even board-certified dermatologists were frequently wrong when trying to identify skin infections just by sight.

As a first step to assessing the situation, the CDC researchers turned to data on prescriptions written for 48.8 million Medicare Part D beneficiaries in 2021. In the whole year, clinicians prescribed 6.5 million topical antifungal treatments. That's enough prescriptions for about one out of every eight Medicare Part D beneficiaries to get an antifungal.

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Among the total dataset of Medicare prescribers, there were a little over a million prescribing clinicians, but only about 131,000 of those clinicians prescribed topical antifungals. When those prescribers were ranked by the volume of antifungal treatments they prescribed, the top 10 percent—13,106 prescribers—accounted for about 45 percent of all the antifungal prescriptions written that year, or 2.9 million of the total 6.5 million.

Problematic prescribers

Most of the year's topical antifungal prescriptions were written by primary care physicians, who wrote about 40 percent of the prescriptions. They were followed by nurse practitioners/physician assistants, dermatologists, and podiatrists.

The most common prescriptions were for ketoconazole, nystatin, and clotrimazole-betamethasone dipropionate, a combination medicine containing an antifungal and a corticosteroid. The latter is particularly concerning since the combination is thought to be a driver of drug resistance.

While the data points to some providers potentially overprescribing antifungal medications—and some antifungal medications that are particularly prone to driving resistance—the researchers didn't have diagnostic data on the cases. Thus, they couldn't tell how many antifungal prescriptions were backed up by diagnostic testing confirming a fungal infection. That said, another limitation of the study is that it didn't capture the use of over-the-counter antifungal medications. Therefore, the use of antifungals among Medicare beneficiaries is likely underestimated.

The study is a preliminary step to improving antifungal stewardship, the authors note. But "the substantial volume of topical antifungal and antifungal-corticosteroid prescriptions among Medicare Part D beneficiaries in the setting of emerging resistant infections underscores the need to evaluate current practices of topical antifungal use," the authors conclude. Clinicians should "be judicious," they caution, and confirm fungal skin infection diagnoses when possible.

Helen Mirren Trusts This Unexpected Gel — Only $16 — For All Her On-the-go Skin-care Emergencies

We're obviously big fans of Helen Mirren here — and honestly, who isn't? The Dame is an absolute icon of class, talent and ageless glamour, and every time she shares one of her beauty secrets, we sit up and take note. In an "Inside My Beauty Bag" interview with Harper's Bazaar UK, Mirren shouted one one item she depends on that took us by surprise: a topical colloidal silver gel, like the Silver Miracles Colloidal Silver Gel. We know that colloidal silver has been the topic of much debate and controversy in the last few years ... But we figured if Helen loves it, it's worth looking into!

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Helen Mirren says that a dab of this gel "just magically sort of resolves" unexpected skin problems, like rashes or irritation.

$16 at Amazon

So... (Jerry Seinfeld voice) what's the deal with Silver Miracles Colloidal Silver Gel? Let's begin with what Dame Helen herself said about a very similar product: "This is very interesting," noted the Oscar-winning actress as she pulled the gel out of her makeup bag. "I do like to travel with this, because you know, when you're traveling all sorts of things can happen to your skin ... You can get a rash or something can go wrong, and this [colloidal silver gel] ... A little dab of that on, if you have a rash or something going wrong with your skin, a dry patch, this stuff just magically sort of resolves it. I do recommend it."

Due to some pandemic-era controversy, colloidal silver can be seen as a contentious ingredient. However, in this case, there's a major difference between the widely debated consumption of colloidal silver versus the use of the ingredient topically, as with this gel. Colloidal silver was first used topically to treat infections and wounds before antibiotics were widely available, and while the FDA has warned that using colloidal silver as a dietary supplement is not a safe or effective way of treating disease, there are more promising possibilities when it comes to its use in skincare. According to the Center for Research on Ingredient Safety at Michigan State University, "When applied topically, silver can inhibit the growth and reproduction of bacteria. However, it doesn't destroy bacteria the way bactericidal agents like an antibiotic kills bacteria. ... You should avoid consuming ionic or colloidal silver orally." Conversely, "You can safely use products containing colloidal or ionic silver designed for topical use on your skin." The CRIS also notes that anyone using topical colloidal silver should follow the product's directions, and concludes, "Silver-containing ointments and products designed for our skin can be highly effective and safe ways to prevent excessive bacterial growth.

With that out of the way, let's check out the benefits of Silver Miracles Colloidal Silver Gel.

The brand says that their colloidal silver gel is designed for all skin types — dry, oily and everything in between. The gel contains 99.999% pure silver and is paraben-free, gluten-free and contains no added colors or fragrances. Its first usage is for soothing and cooling burns and sunburns — think of it like super-aloe. Presumably thanks to colloidal silver's antibacterial properties, the gel helps gently soothe burns while promoting healing of the skin, with the gel texture helping ensure maximum absorption. It also helps dry and irritated skin in the same way, which is likely why Ms. Mirren notices a difference in her own skin foibles whenever she uses it.

When it comes to recommending skincare for ageless-looking skin, no one does it like the Dame. (Getty/Amazon)

Over 7,000 Amazon shoppers agree — Silver Miracles Colloidal Silver Gel deserves a perfect five-star rating. "Great for minor burns," shared one customer. "I learned about this product the hard way: in a professional bakery kitchen. My arm collided with a hot tray of croissants and it seared me. This gel worked wonders! It immediately killed the pain. Highly recommend for minor burns from hot ovens and stoves."

"Good for [skin] repair," wrote another user. "Had a face procedure done and was recommended to use this product to help heal — worked great!" Said this fan: " I also suffer from acne and super sensitive skin, and t's hard to find something that is strong enough to keep my skin clear but doesn't irritate. The capacity this gel has for healing is incredible. It is cold and soothing and has never stung any of my cuts or blemishes. And you can cake it on to where it forms a thin layer of protection ... Almost like liquid skin. I even add it to my hand creams to give my lotion an antimicrobial boost!"

"So, I never really ever leave a review, but here I am," confessed one Amazon-ian. "I have pretty bad eczema. ... I have been on topical steroids for years and nothing has helped in such a small amount of time than this miracle gel! I got it on Thursday, today is Saturday, have applied it for two days and on day one, I already felt relief. I even had a small rash on my stomach; I rubbed some in, and in a day the rash is gone!"

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At only $16, this gel is a steal when it comes to celeb skin-care favorites.

$16 at Amazon

The reviews quoted above reflect the most recent versions at the time of publication.

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