Eczema Knowledge Hub

For most people, eczema is managed well with moisturisers, topical steroids, and good trigger avoidance. But for those with moderate-to-severe disease — where the skin is inflamed over a large area, sleep is broken most nights, and daily life is significantly affected — these standard approaches are sometimes not enough. Over the last decade, a new class of targeted therapies has changed what is possible for this group.

Why do some people need more than topical treatments?

Eczema is driven by an overactive immune response, particularly involving two signalling proteins called IL-4 and IL-13, which promote inflammation and disrupt the skin barrier. In severe disease, topical treatments can only do so much because the immune overactivation is systemic — happening throughout the body, not just at the skin surface. This is where biologics and newer oral treatments come in: they work from the inside, targeting the specific immune signals driving the disease rather than simply dampening inflammation broadly.

These treatments are not a first or second step. They are considered only after topical therapies and basic skincare have been tried consistently and found insufficient, and they require diagnosis and monitoring by a dermatologist.

Dupilumab (Dupixent)

Dupilumab was the first biologic approved specifically for moderate-to-severe atopic dermatitis. It is given as a subcutaneous injection every two weeks and works by blocking both IL-4 and IL-13 simultaneously. In large clinical trials, roughly 40–50% of adults and adolescents achieved clear or almost clear skin within 16 weeks of starting treatment, and most experienced a significant reduction in itch — often one of the most debilitating aspects of severe eczema.^[1]

Dupilumab is now approved for patients as young as 6 months of age in many countries, making it an option for children with severe, treatment-resistant disease. It does not suppress the immune system broadly, which means the infection risks associated with older immunosuppressant drugs do not apply. The most common side effects are mild: eye irritation (conjunctivitis) and a reaction at the injection site.

Other biologics

Newer injection therapies targeting IL-13 specifically — tralokinumab and lebrikizumab — have since been approved for moderate-to-severe AD in adults. They offer similar outcomes to dupilumab and provide additional options for people who do not respond adequately or experience side effects with dupilumab.^[2] The availability of these options varies by country, and a dermatologist will advise on what is accessible and likely to work for your specific disease pattern.

JAK inhibitors

Oral medications called JAK inhibitors — including upadacitinib, abrocitinib, and baricitinib — act on a different part of the immune pathway. They work more quickly than biologics, often reducing itch within days, and can be highly effective for severe disease. However, they carry a more significant safety profile than biologics, including an increased risk of infections, and in some populations, risks of blood clots and cardiovascular events. Regulatory agencies in several countries have added black box warnings to these medications, and they are generally reserved for cases where biologics have not provided adequate control or are not suitable.^[3] Ongoing monitoring is required.

Are these treatments right for you?

These therapies are not suitable for everyone with eczema — they are specifically indicated for moderate-to-severe disease that has not responded adequately to topical treatments. If you are wondering whether you might be a candidate, here are the questions worth discussing with a dermatologist:

• Has your eczema significantly affected your quality of life — sleep, work, relationships — despite consistent use of prescribed treatments?
• Have you tried at least one or two topical therapies including corticosteroids and been under the care of a doctor for your skin?
• Are you able to attend regular follow-up appointments for monitoring?

Cost and access are real considerations. Dupilumab in particular is expensive without insurance or subsidy coverage, and approval criteria vary by country. Some health systems have specific severity thresholds or require prior failure of other treatments before funding is granted. Your dermatologist can advise on what is available and how to navigate the process.

What does not change

Even for people who respond well to biologics, moisturising daily and avoiding known triggers remain important. These treatments calm the immune system's overreaction, but they do not rebuild the skin barrier on their own. A consistent skincare routine is still your foundation — it just works better when the underlying inflammation is under control.

If you think your eczema may be severe enough to warrant one of these newer treatments, start by asking your GP for a dermatology referral. The conversation with a specialist is the right first step.