Light therapy and oral medications

Photo of a man who has eczema (PantherMedia / nebari)

Eczema can usually be kept at bay by moisturizing your skin enough, applying anti-inflammatory ointments or creams, and avoiding irritants. If this isn't enough, light therapy with UV rays or treatment with tablets can be considered.

Some people have such severe eczema flare-ups that using ointments or creams to reduce the inflammation doesn't relieve the symptoms enough. During acute phases like this, light therapy may be used. If this doesn't work well enough either, tablets that suppress the body's immune response are an option.

Light therapy

Light therapy, also known as phototherapy, involves exposing the affected areas of skin to ultraviolet light (UV light). UV light inhibits the inflammatory response in the skin, and also influences cell division. The treatment takes place in special cabins with fluorescent lamps that emit light of a certain wavelength. There are also lamps that can be used to treat individual parts of your body, such as your head, hands or feet. Tanning beds can't be used for this purpose.

Light therapy usually involves two to six sessions per week in a specialized dermatological practice or hospital. The treatment lasts between four weeks and three months. In order to allow the skin to gradually get used to the radiation, the dose is adjusted to the patient's skin type and slowly increased.  Light therapy sessions typically take less than a minute at first, and up to several minutes toward the end of the treatment.

Different kinds of light therapy

There are different kinds of light with different wavelengths, known as UVA rays and UVB rays. Treatment of eczema nowadays mostly uses what is known as narrowband UVB phototherapy. Here the skin is only exposed to UVB rays with a wavelength of 311 to 313 nanometers. Limiting the light spectrum in this way reduces the risk of side effects.

There is also another option called “psoralen plus ultraviolet A” (PUVA) therapy. This involves taking the medication psoralen first, in order to make your skin more sensitive to light. Then, about two hours later, the skin is exposed to UVA rays. Alternatively, a psoralen cream or gel can be applied to the affected areas of skin first.

As well as using the right wavelength of light, the right dose and duration of light therapy has to be determined too. Many different factors play a role here, including what kind of skin you have, the type and number of previous treatments, whether you have had other medical conditions such as skin cancer, and whether you are taking medication that makes your skin more sensitive to light, like NSAIDs or antibiotics. So it's a good idea to find a doctor who has a lot of experience with light therapy.

There are also other kinds of light therapy, such as UVA1 phototherapy and balneo-phototherapy. Balneo-phototherapy is a combination of bathing and UV light therapy. You can either be exposed to the UV light while bathing or after bathing.

But statutory health insurers in Germany generally don't cover the costs of UVA1 phototherapy or balneo-phototherapy when used for eczema.

Benefits and drawbacks of light therapy

Research has shown that light therapy can effectively relieve the inflammation as well as other symptoms such as itching, allowing the skin to heal for a while. But it can’t make eczema go away in the long term.

What’s more, two studies have suggested that combining light therapy with bathing therapy has advantages: Compared to treatment with UV light alone, bathing while being exposed to UV light can lead to a greater improvement in the condition of the skin, and probably reduce itching and sleep problems too.

UV light therapy involves quite a lot of effort because several sessions are needed per week. Although the sessions are quite short, the treatment takes up a lot of time because you have to drive there, wait in the waiting room, and then apply moisturizing skin care products afterwards. So people who have a busy work and family life might find it hard to stick to this treatment.

And UV rays can have various side effects. For instance, the radiation can dry out your skin. So it's important to apply enough moisturizing cream afterwards. Sunburn-like skin irritations may occur too. This is particularly likely in people who tend to get cold sores on their lips. To try to prevent this from happening, you can use sunscreen on your lips. Other, less common, side effects include raised red patches that go away again and hair follicle infections. Frequent exposure to UV radiation can also lead to premature aging of the skin and increase the risk of skin cancer. Taking psoralen for PUVA therapy can cause nausea and vomiting.

In order to limit side effects as much as possible, it's important to avoid sunlight on the day of treatment, or protect yourself from natural UV light by wearing appropriate clothing, sunglasses and sunscreen. This is particularly important for people who have taken psoralen. They should avoid exposure to natural sunlight for the rest of the day.

A UV diary can help you keep track of the UV treatments you have had. Information about the number of sessions and radiation dose used can be entered into it.

Treatment with tablets

If other treatments don't work well enough or aren't an option, treatment with tablets is possible. These include:

  • Azathioprine
  • Ciclosporin
  • Steroids
  • Methotrexate (MTX)
  • Mycophenolate

All of these belong to a group of medications known as immunosuppressants which, as the name suggests, suppress the immune system. Because of this, they can have serious side effects – particularly if taken over longer periods of time. But serious side effects are rare with most of these medications.

Ciclosporin

Ciclosporin has long been approved in Germany for the treatment of eczema, and it is the best studied eczema medication. A number of studies have shown that it can relieve eczema. So ciclosporin is often the first treatment of choice if tablets are needed.

It is taken in the morning and evening, at the same time every day if possible. The dose is determined based on your body weight, and is reduced as soon as the eczema starts to improve. The duration of treatment will depend on how well the medication works. This could be anything from several weeks to six months. But treatment is rarely continued for longer than six months due to the possible side effects.

Ciclosporin suppresses the immune system, so it may increase the likelihood of getting infections. Other possible side effects include swollen gums, trembling and gastrointestinal (stomach and bowel) problems. Ciclosporin can also put a strain on your kidneys and increase your blood pressure.

Because of this, regular check-ups to monitor your kidneys and blood pressure are recommended during the treatment.

Ciclosporin shouldn't be combined with light therapy because this can increase the risk of non-melanoma skin cancer. The same is true for people who have already had many years of light therapy.

Because ciclosporin can interact with other drugs, it's important to let your doctor know about any other medication you are using before you start taking ciclosporin. This is also true for herbal products. For instance, St. John's Wort can weaken the effect of ciclosporin.

Azathioprine

If treatment with ciclosporin isn't possible or doesn't work, azathioprine is an alternative option. This drug hasn't yet been approved in Germany for the treatment of eczema. So it can only be prescribed for this purpose in exceptional cases, and this "off-label use" has to be justified.

A few studies have suggested that azathioprine can help in eczema. But there hasn't been enough good-quality research to be able to draw reliable conclusions about its effectiveness. Azathioprine often causes gastrointestinal (stomach and bowel) problems, can affect your bone marrow and put a strain on your liver.

Oral steroids

Some family doctors often still prescribe oral steroids (steroid tablets), particularly for adults with severe eczema. But they are no longer recommended for the treatment of eczema, and should only be used in exceptional cases. This is because, on the one hand, the eczema often returns when you stop taking the tablets – and then tends to be even worse than before ("rebound effect"). On the other, oral steroids can have serious side effects when taken for a longer period of time. If you take oral steroids, then you should only take them for a few days, or two to three weeks at most.

Other medications

There is very little research on the effectiveness of other oral medications (tablets) in the treatment of eczema, such as methotrexate. It's a good idea to have an in-depth talk with your doctor before deciding whether to take eczema medication that affects your whole body.

Allergy medications (antihistamines)

Sometimes eczema is treated with allergy medications known as antihistamines. Antihistamines inhibit the effect of histamine, a chemical compound produced by the immune system when foreign substances enter the body. Histamine dilates (widens) the blood vessels and causes more blood to flow through the tissue. It also irritates the nerves, causing itching.

Antihistamines are used for the relief of itching in eczema. But they weren't found to be effective in studies on eczema. Some antihistamines make you feel tired so they might help reduce sleep problems that are caused by itching. But because they don't relieve the symptoms of eczema, they aren't usually recommended as a treatment. It might make sense to use antihistamines if you have eczema as well as other allergies such as hay fever, though.