When you or your child has atopic dermatitis, your doctor might prescribe a topical medication (the kind you apply to your skin). Topical steroids are widely used. But sometimes these don’t work well enough. Or maybe you’re discouraged by the side effects.
In that case, your doctor can try another type of prescription treatment. One of the newer choices is a phosphodiesterase-4 (PDE-4) inhibitor. This type of drug reduces inflammation and stops itching by blocking an enzyme in the inflammatory process.
How Do PDE-4 Inhibitors Work?
PDE-4 enzymes produce proteins called cytokines, which signal your immune system to get to work. In people with healthy skin, this helps protect against harmful substances. But if you have atopic dermatitis, your PDE-4 enzymes are overly active. They produce too many cytokines.
This leads to inflammation and the red, itchy skin of atopic dermatitis. By blocking PDE-4, PDE-4 inhibitors inhibit or hinder this process.
The FDA has so far approved three topical PDE-4 inhibitors for atopic dermatitis:
- Crisaborole (eucrisa) ointment is available in a 2% concentration. The ointment not only delivers the medication, but also helps your skin stay moisturized. It's approved for use in people as young as 3 months old.
- Difamilast (Adquey) ointment is available in a 1% strength. It's approved for adults and children aged 2 and older.
- Roflumilast (Zoryve) cream comes in concentrations of 0.15% and 0.05% for atopic dermatitis treatment. Children ages 2-5 can use roflumilast as an alternative to steroids.
When Are PDE-4 Inhibitors Prescribed?
Crisaborole (Eucrisa) and difamilast (Adquey) are FDA-approved to treat mild to moderate atopic dermatitis in both adults and kids. (Atopic dermatitis is classified as mild, moderate, or severe depending on how much of your skin it affects, and how bad your symptoms are.)
These medications can be used by people of any ethnicity or skin tone. You can use it over longer periods than topical corticosteroids. And, unlike corticosteroids, you can use it on delicate areas like your face, eyelids, and skin folds.
But they tend to be more expensive than topical corticosteroids. For example, a month’s supply of crisaborole (Eucrisa) can cost more than $700 (without insurance). So your health insurance may not cover this medication unless you’ve tried other treatments first.
You might get approval only if:
- You’ve tried at least two topical corticosteroid ointments, but they didn’t improve your symptoms
- You couldn’t tolerate the side effects from other medicines you tried
- Your eczema is in a sensitive body part where you can’t use other medicines
- Your child is younger than 3 months, so can’t use medicines containing calcineurin inhibitors
Roflumilast cream (Zoryve) is approved for topical use for mild to moderate atopic dermatitis. Adults and kids 6 and older can use the 0.15% cream. Kids 2-5 can use the 0.05% cream.
If you’re pregnant, breastfeeding, or trying to get pregnant, talk to your doctor about whether one of these topical PDE-4 inhibitor is safe for you. Also, let your doctor know what other medications and supplements you’re taking. Some may interact with crisaborole or difamilast ointments or roflumilast cream.
What to Expect When You Use Topical PDE-4 Inhibitors
It’s important to carefully follow your doctor’s instructions for using topical PDE-4 inhibitor. Usually, you’ll apply a thin layer of the medication once or twice a day to areas where you have atopic dermatitis symptoms.
For best results, put it on as soon as you get out of a bath or shower. Wait 15 minutes before using moisturizer. Wash your hands after applying it, unless you’re using it to treat atopic dermatitis on your hands.
If you accidentally skip a dose, apply the ointment as soon as you remember to. If it’s almost time for your next dose, just stick to your regular schedule. Don’t use extra ointment to make up for the missed dose.
Depending on which topical PDE-4 you use, it may take anywhere from a few days to a few weeks for the medication to fully work. In some studies, people saw improvement in their atopic dermatitis inflammation in as little as 2 days after starting the medication. About a third of study participants had clear or almost clear skin after using the ointment twice a day for 28 days. Ask your doctor when you might expect to see results.
These medications work best when you also follow your doctor’s advice about bathing, moisturizing, and managing triggers.
You might use a PDE4 inhibitor steadily, or on and off as needed to treat flare-ups.
What Are the Possible Side Effects?
Rarely, a PDE4 inhibitor ointment can make your skin burn or sting just after you put it on. But keeping it cold can reduce that feeling. Keep the tube in your refrigerator if this happens to you. In studies of crisaborole, a few people got skin infections or noticed that their skin symptoms got worse. Tell your doctor if you have these side effects.
It’s also possible to have an allergic reaction to this medication. Stop using it if you get hives, bad itching, swelling, or redness.
Roflumilast cream side effects may include:
- Feeling sick or throwing up
- Headache
- Diarrhea
- Pink eye
- Upper respiratory tract infection
- Rhinitis (sneezing or stuffy nose)
