Mike: Hello, I'm Mike Clarke, podcast editor for the Cochrane Library. The Cochrane Skin group has produced more than 100 reviews. These were added to in August 2024 by a new network meta-analysis of topical anti-inflammatory treatments for eczema. We asked lead author, Robert Boyle from Imperial College London in the UK to tell us about the condition and the findings of his review in this podcast.

Bob: Eczema is a common inflammatory skin condition which causes itching, redness and cracking of the skin. There is no cure and the main approaches for easing the symptoms are moisturisers, avoiding common triggers, and topical anti-inflammatory treatments such as steroid creams. There are many topical anti-inflammatory treatments, with new ones likely to become available soon. We did this Cochrane review to try to understand which are most effective and safest. By doing this as a network meta-analysis, we were able to indirectly compare different topical anti-inflammatories, even if they had not been directly compared with each other in a clinical trial.
We started by asking groups of people affected by eczema what they were most interested in. They emphasised the importance of long-term outcomes and safety as well as effectiveness, so we tried to focus on these in the review.
We looked for randomised trials of the application of topical anti-inflammatory treatments to the skin of people with eczema. We didn’t include trials for specific forms of eczema such as contact dermatitis or hand eczema, and we didn’t include treatments such as antibiotics, moisturisers or tablets, which are covered by other Cochrane reviews.
So what did we find? There were close to 300 studies with results reported, including a total of more than 45,000 people with eczema. Most took place in wealthier countries, focused on adults and were limited to short-term outcomes over a few weeks. Almost all the studies were either funded by companies that make topical anti-inflammatory treatments, or didn’t state their funding source.
Our first major finding is that many doing trials in this area are not transparently reporting their results. This means that most of our findings are uncertain, due to lack of information about study plans and full study results.
In terms of effectiveness, three groups of topical anti-inflammatory treatments seem to be among the most effective: potent steroids, janus kinase inhibitors such as ruxolitinib, and tacrolimus 0.1% ointment, but there wasn’t enough information to confidently state which group is most effective. We found phosphodiesterase-4 inhibitors, such as crisaborole, were among the least effective treatments.
For safety, the side effect of burning or stinging when treatment is applied was most common with tacrolimus, pimecrolimus and crisaborole; and least likely with steroids. Skin thinning was not significantly increased with any of the treatments during short-term use over less than 16 weeks but was reported in about 1 in 300 people who used mild, moderate or potent steroids for longer durations, of 6 months to 5 years. All three studies reporting skin thinning with longer term use of steroids were funded by manufacturers of competitor topical anti-inflammatory treatments.
Unfortunately, despite the importance to people with eczema, there was not enough information on long-term effectiveness and safety of topical anti-inflammatory treatments, so more work is needed there. We also didn’t formally evaluate cost or cost effectiveness. But, in general, topical steroids are marketed at prices which are 4 to 20-fold lower than tacrolimus, pimecrolimus, crisaborole, ruxolitinib or other novel topical anti-inflammatory treatments.
In summary, and with variable confidence, our network meta-analysis identified potent steroids, janus kinase inhibitors and the topical calcineurin inhibitor tacrolimus 0.1% as among the most effective short-term treatments for eczema. Topical steroids may have the lowest risk of stinging and burning, and are cheaper than the other topical anti-inflammatory treatments. However, long-term use of topical steroids may carry a small risk of skin thinning, but more much work is needed to evaluate long-term outcomes for all the treatments. Future trials also need to adhere to modern reporting standards for transparency, so that more confident assessments can be made of the relative effectiveness and safety of eczema treatments.

Mike: If you’d like to read the review, learn more about the hundreds of trials that have already been done and watch for future updates of the review, if you go to CochraneLibrary.com and search ‘anti-inflammatory treatments for eczema’ to see a link to its open access version.