Eucrisa - A New Eczema Treatment

Jan 8, 2019

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

Best. Uncle. Ever. My own children ignore me. When I pick up Eric after hockey practice, he'll walk right past me in the arena lobby without so much as a hello. If Emily notices me in the house, I might get an acknowledgement like, "Why are you here? Shouldn't you be at work?" To which I answer, "It's Saturday". That will earn me a shrug as she strides past. But not my niece, Bailey. Before Christmas, she noticed an ad for the movie Die Hard. She told her mom, "That's Uncle Trevor's Christmas Movie!" When she came up here for the holidays, she insisted the family binge on Die Hard movies. Nothing says Christmas like a cursing Bruce Willis shooting guys with foreign accents.

As you move through the Die Hard series, you might be itching to know why a progressively balding Bruce Willis kept being cast as the leading man. The obvious answer is bald men are better looking. If you have been scratching a physical itch and have a rash that has been going away and coming back since childhood, you might have eczema. Eczema is a skin condition that can affect up to 20% of children and up to 10% of adults. It usually begins childhood and in some people it continues on into adulthood. It is possible that the first flare up of eczema starts in adulthood. The eczema rash often goes away and comes back in the same individual. Eczema runs in families, and often the patient with eczema also has asthma and allergic rhinitis.

The rash in eczema is red and itchy. It can also be dry, scaly or oozy. The location of the eczema rash changes as the patient ages. In infants the rash tends to be on the face and the outside of joints like the outside of the elbow. In older children, eczema tends to be on the neck and the inside of joints like the inside of the elbow. In adults, it tends to stay on the inside of joints but can also appear on the hands.

The first line of treatment for eczema is moisture. People with eczema should liberally apply moistures twice a day and especially after a bath or shower. The shower puts the moisture into the skin and a good moisturizer can hold it in. Showers should be warm, not hot and relatively short. During the shower, try to use as little non-irritating soap or cleanser as possible. The best moisturizers are the greasy ones. Vaseline or the more cosmetically appealing Vaseline Creamy, and Aquaphor are fantastic at keeping moisture in the skin, but many people don't like the greasy feeling. So, the best moisturizer is the one the patient will agree to use liberally everyday.

Eczema is also known as atopic dermatitis and it is more than just dry, itchy skin. It has two main things going on: impaired skin barrier function and immune dysfunction. The barrier function of the skin can be improved with moisturizes as already mentioned. The problems with the immune system are more difficult to treat. A recent survey found 1 in 4 children experience sleep loss due to their eczema. In the past 2 years with eczema, 28 % of children had seen a doctor 4 or more times for their skin condition. One in four children had missed 10 or more days of school per year due to their eczema. So, it really can affect the child's quality of life.

After staying moisturized, the next step is avoiding things that can irritate the skin and trigger an eczema flare up. Irritants will vary person by person but can include things like wool clothing, excessive heat or various perfumes.

Even after we've kept the skin moisturized and avoided eczema triggers, there still will be flare ups. When they happen, we will probably reach for a cream that reduces inflammation. The first line treatment is still the topical steroids. They have names like hydrocortisone, betamethasone and mometasone. They work well, but we have to be careful to use each in the right places. Hydrocortisone is a low potency steroid, so that makes it a good choice for the sensitive skin on the face. The mild steroids will probably be used twice a day, every day. Betamethasone is too strong for the face, but would be a good choice for the thicker skin on the palms of the hands. Mometasone is interesting. It was marketed as being gentle enough for the face, but strong enough to work well on other parts of the body. I think this makes mometasone closer to a one size fits all cream for eczema. These moderate strength steroids might be used daily, but depending on severity, might be used more like a few times a week.

Steroids might not be the best treatment for all patients. About 20% of children surveyed found their current eczema treatments painful to apply and less than 1/3 of parents thought their child's current eczema treatment was working well.

Topical calcineurin inhibitors with names like pimecrolimus and tacrolimus are alternatives to topical steroids. They first came out about 15 years ago. They affect some of the white blood cells in the immune system called T cells and some of the immune signaling chemicals called cytokines. When the topical calcineurin inhibitors modulate the immune system, they reduce inflammation in the skin. They work about as well as a mid-potency topical steroid. However, they don't run the risk of thinning the skin like steroids. In that way they are considered safer. And they are okay for sensitive areas like the face. But at a little less than $100 per month, they are more expensive than steroids.

The newest alternative to steroids is called crisaborole or Eucrisa. Crisaborole works by inhibiting the enzyme phosphodiesterase 4 or PDE4. PDE4 converts something called cyclic adenosine monophosphate (cAMP) in AMP. When crisaborole stops the conversion of cAMP to AMP that decreases the production of chemical messengers called cytokines. The reduction of cytokines suppresses the immune system. Crisaborole is similar in price to the pimecrolimus cream at a little less than $100 per month.

For those of you celebrating Ukrainian Christmas and New Years this week, may I make a suggestion? Listen to your favorite Uncle Trevor. Gather close those most dear to you. Go to Church. Share a good meal. Put a Bruce Willis marathon on the TV for 6 to 8 hours. Cursing, guns and explosions now are synonymous with Christmas for my niece. And they should be for all of you. Merry Christmas and "Yipee Ki Yay" to all.

As always if you have any questions or concerns about these or other products, ask your pharmacist.

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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