Beyond Steroids: Alternative Topical Treatments That Actually Work

By Diane Angela Fong. ND

Sequential images showing visible improvement in atopic dermatitis from Day 1 to Day 14 following use of a custom compounded topical formulation containing vitamin D and vitamin B12, selected to support skin barrier repair and immune regulation. Individual results may vary.

As a naturopathic doctor specializing in eczema, I've seen countless patients caught in the frustrating cycle of topical steroids: apply, improve, stop, flare, repeat. While topical corticosteroids remain effective first-line treatments, many people are seeking alternatives that address the root causes of eczema rather than simply suppressing symptoms.

The good news? Evidence-based alternatives exist, and in my clinical experience, they can provide lasting relief without the concerns associated with long-term steroid use.

In the image above, you can see how the right topical strategy, when appropriately selected, can help calm inflammation and support visible skin healing within as little as 14 days in some cases. I’ll walk through this case in more detail in this post.

Understanding the Limitations of Conventional Treatments

Topical Corticosteroids

Topical corticosteroids are highly effective for acute flares and remain a cornerstone of eczema treatment. Network meta-analyses confirm that potent topical steroids are among the most effective treatments for improving clinical signs. [1-2] However, they work by suppressing inflammation rather than addressing underlying causes.

Long-term concerns include:

• Skin atrophy reported in 0.3% of participants treated with topical steroids for 6-60 months [1]

• Clinical aggravation after treatment cessation

• Patient anxiety about "steroid phobia"

• Risk of topical steroid withdrawal—a controversial but increasingly recognized phenomenon characterized by burning, stinging, and rebound flaring after discontinuation

Calcineurin Inhibitors

Tacrolimus and pimecrolimus are effective alternatives that don't cause skin atrophy. Network meta-analyses rank them among the most effective topical treatments for multiple eczema outcomes. [2] However, they come with their own concerns:

• FDA black box warning regarding theoretical cancer risk (based on animal studies, though not substantiated by 10-year longitudinal cohorts in humans)

• Higher cost than corticosteroids

• More adverse reactions, particularly burning and pruritus in the first few days of use [1]

• Patient anxiety about the black box warning limits acceptance

The Alternative Approach: Addressing Root Causes

What if we could address the underlying drivers of eczema—microbial dysbiosis, barrier dysfunction, and immune dysregulation—rather than simply suppressing inflammation? This is the foundation of my approach using compounded topical formulations.

Zinc Pyrithione: Addressing the Root Cause of Eczema

While Zinc Pyrithione is widely known as an anti-dandruff agent, its benefits extend far beyond seborrheic dermatitis.

The mechanism is multifaceted:

• Broad antimicrobial activity against fungi (including Malassezia species) and bacteria

• Anti-inflammatory effects independent of its antimicrobial properties

• Slow-release reservoir effect for extended benefits

Research confirms that magnesium, zinc, and iodine improve atopic dermatitis through anti-inflammatory and anti-microbial effects. [3]

The Evidence

A head-to-head comparison study in seborrheic dermatitis—a subtype of eczema—evaluated zinc pyrithione against topical betamethasone (a potent steroid) and tacrolimus. All three treatments showed significant improvements after 4 weeks of treatment. [4]

But here's what made zinc pyrithione stand out: patients treated with zinc pyrithione showed continuous improvement even after stopping treatment, while those treated with betamethasone and tacrolimus experienced clinical aggravation after cessation. [4]

This finding aligns with my clinical observations. When we address the microbial dysbiosis that perpetuates eczema inflammation—rather than simply suppressing the inflammatory response—we create conditions for lasting improvement.

My Clinical Experience

I typically use zinc pyrithione at concentrations of 0.1-0.2%. In my practice, this has been particularly effective for patients with:

• Evidence of Malassezia overgrowth

• Eczema that flares in seborrheic distribution areas

• Patients who have failed or cannot tolerate conventional treatments

• Those seeking long-term maintenance without steroids

Vitamin D: Supporting Barrier Function and Immune Regulation

The Rationale

Children and adults with eczema often have lower vitamin D levels than those without eczema. Meta-analyses have demonstrated that serum 25-hydroxyvitamin D levels are significantly lower in atopic dermatitis patients compared to healthy controls, with this difference being particularly pronounced in pediatric patients. [5]

Vitamin D supports skin health through multiple mechanisms:

• Strengthening the skin's protective barrier

• Reducing inflammation through immune-regulatory pathways

• Supporting the skin's natural antimicrobial defenses

Emerging Evidence for Topical Vitamin D

While most clinical trials have focused on oral supplementation, preclinical research supports the potential of topical vitamin D:

• A 2023 study demonstrated that topical calcitriol (active vitamin D3) decreased dermatitis scores and epidermal thickness in atopic dermatitis mouse models. Importantly, it improved both stratum corneum barrier function and tight junction barrier function, while reducing inflammatory cytokines IL-13 and IL-33. [7]

• A 2022 study comparing topical vitamin D3 cream (0.0003%) to topical betamethasone in mice found that vitamin D3 produced marked improvement in skin with significant reduction in IgE levels, IL-5, and epidermal thickness—highlighting its anti-inflammatory effects. The authors concluded this "represents a new paradigm" for atopic dermatitis treatment. [8]

Important Considerations

Early research raised concerns that certain topical vitamin D analogs might exacerbate symptoms by inducing TSLP expression in keratinocytes. [9] A 2015 review also noted that "topical vitamin D is not recommended because it can worsen skin lesions." [10]

However, more recent evidence indicates that formulation and vehicle matter significantly. When compounded at appropriate concentrations, vitamin D can help strengthen the skin barrier and reduce inflammation without the concerns seen with high-potency vitamin D analogs used in psoriasis treatment.

In my clinical experience, topical vitamin D works synergistically with zinc pyrithione and other topical nutrients.

Vitamin B12: The Gentle Anti-Inflammatory

The Science

Vitamin B12 is an effective scavenger of nitric oxide (NO). Research has shown that NO synthase inhibition leads to decreased pruritus and erythema in atopic dermatitis, making vitamin B12 a logical therapeutic option. [11]

What makes B12 particularly appealing is its mechanism: it reduces inflammation without immunosuppression, making it safe for sensitive areas like the face and eyelids, and suitable for long-term use in children.

Clinical Trial Evidence

The evidence for topical vitamin B12 is compelling:

Phase III Multicentre Trial: A randomized, placebo-controlled trial of 49 patients over 8 weeks found that the modified Six Area Six Sign Atopic Dermatitis score dropped significantly more on the vitamin B12-treated side compared to placebo (55.34% vs 28.87% reduction, P 0.001). At study conclusion, 58% of investigators and 59% of patients rated the active drug as "good" or "very good." The treatment was very well tolerated with very low safety risks. [11]

Comparative Trial: A randomized left-to-right comparative trial of 22 patients over 4 months compared a vitamin B12-barrier cream to standard glycerol-petrolatum-based emollient cream for mild atopic dermatitis. The results were striking: the B12 cream achieved a 77.6% SCORAD reduction compared to 33.5% with standard emollient.

Meta-Analysis Confirmation: A systematic review and meta-analysis of vitamin supplements in eczema found that topical vitamin B12 significantly reduced eczema severity (mean difference -3.19, 95% CI: -4.27 to -2.10). [6]

Pyridoxine (Vitamin B6): Restoring Filaggrin Production

The Science

Filaggrin is a protein essential for maintaining a healthy skin barrier—and many people with eczema have reduced filaggrin levels due to genetic mutations or inflammatory damage. This is where pyridoxine becomes particularly interesting.

Research has demonstrated that pyridoxine stimulates filaggrin production in human epidermal keratinocytes. [12] By directly promoting the synthesis of this critical barrier protein, topical vitamin B6 may help address one of the fundamental defects underlying eczema.

Additionally, pyridoxine enhances the skin's antioxidant system and restores expression of other skin barrier-related proteins, including serine palmitoyltransferase—an enzyme important for ceramide synthesis. [13] Ceramides are essential lipids that help maintain the skin's moisture barrier.

Clinical Considerations

While oral pyridoxine supplementation did not show benefit in a pediatric eczema trial, topical application may work through different mechanisms by directly stimulating filaggrin production in the skin. [14] This makes it a logical addition to formulations targeting barrier repair, particularly in patients with known or suspected filaggrin deficiency.

In my practice, I sometimes include pyridoxine (typically at 5%) in combination with vitamin D and B12 for patients who need comprehensive barrier support.

Niacinamide (Vitamin B3): The Barrier-Strengthening Multitasker

The Science

Niacinamide (also called nicotinamide) is a water-soluble form of vitamin B3 that has emerged as a versatile ingredient for skin health. Its mechanisms of action are multifaceted:

• Anti-inflammatory effects: Niacinamide controls NFκB-mediated transcription of inflammatory signaling molecules by inhibiting PARP-1 (poly ADP-ribose polymerase-1). It also inhibits IL-8 production through the NF-kappaB and MAPK pathways. [15-16]

• Barrier strengthening: Topical niacinamide increases stratum corneum thickness, produces larger and more mature corneocytes, and decreases transepidermal water loss (TEWL). [17]

• Antipruritic effects: Niacinamide has documented antipruritic (anti-itch) properties, which is particularly relevant for eczema patients. [15]

• Antimicrobial activity: It demonstrates antimicrobial effects that may help address skin dysbiosis. [15]

Clinical Evidence in Atopic Dermatitis

A 2023 randomized controlled trial of 122 adults with mild atopic dermatitis found that niacinamide-containing emollients significantly improved SCORAD scores, pruritus (itch), quality of life, and skin barrier function compared to control. Specifically, the niacinamide group showed significantly better transepidermal water loss and stratum corneum water content—objective measures of barrier function. [18]

An earlier study comparing 2% topical nicotinamide cream to white petrolatum in 28 patients with atopic dermatitis found that nicotinamide significantly decreased transepidermal water loss, while petrolatum did not. Both increased stratum corneum hydration, but nicotinamide was significantly more effective. The authors concluded that "nicotinamide cream is a more effective moisturizer than white petrolatum on atopic dry skin, and may be used as a treatment adjunct in atopic dermatitis." [19]

An evidence-based review of topical micronutrients in atopic dermatitis concluded that "topical B, C, and E formulations appear to provide some benefit to AD individuals." [3]

Safety Profile

Niacinamide is well-tolerated and safe, with decades of use in cosmetics and skincare. Clinical studies affirm its effectiveness with minimal adverse effects, even with prolonged use. [20]

Additional Compounded Options

While topical nutrients form the foundation of my alternative approach, I also evaluate patients for other compounded topical treatments that may be beneficial depending on their specific presentation.

Topical Naltrexone

For patients with significant pruritus (itching), topical naltrexone can be a valuable addition. As an opioid receptor antagonist, it works through different pathways than antihistamines. A randomized, placebo-controlled, crossover trial of 40 patients with atopic dermatitis found that topical naltrexone 1% cream achieved a 70% pruritus response rate, with rapid relief—the naltrexone formulation required a median of only 46 minutes to reduce itch symptoms by 50%, compared to 74 minutes for placebo. [21]

Each patient's eczema is unique, and what works best depends on the underlying drivers of their condition. During an Eczema Clarity Visit, I assess the potential root causes of a patient's eczema and discuss using compounded topicals, if appropriate.

The Power of Combination Therapy

In my practice, I've found that combining these ingredients produces synergistic effects that exceed what any single ingredient can achieve alone. Rather than using a one-size-fits-all approach, I tailor formulations based on each patient's specific presentation:

Presentation	Recommended Combination	Rationale
Active inflammation + itch	B12 + Niacinamide	Dual anti-inflammatory action via NO scavenging and NFκB inhibition
Barrier dysfunction + dryness	B6 + Vitamin D	Stimulates filaggrin production while strengthening barrier
Malassezia-associated eczema	Zinc Pyrithione + Vitamin D	Addresses microbial trigger while supporting barrier repair
Comprehensive/refractory cases	B12 + B6 + Vitamin D + Zinc Pyrithione	Multi-pathway approach for complex presentations
Significant pruritus	Add Naltrexone	Targets itch through opioid receptor

A Real Patient Story: From Severe Eczema to Clear Skin

One of the most rewarding aspects of my practice is witnessing the transformation that occurs when we address the root causes of eczema rather than simply suppressing symptoms. I want to share a case that beautifully illustrates the power of this approach.

The Challenge

A young child presented with significant eczema affecting multiple areas, including the inner arm and ankle. The images from Day 1 show the classic presentation: intense erythema (redness), scaling, excoriations from scratching, and the lichenification that develops from chronic inflammation. Any parent who has watched their child suffer through sleepless nights of itching knows how heartbreaking this condition can be.

The Approach

Rather than reaching for topical steroids, we took a different path. The treatment plan included:

• Topical Vitamin D, B12, Pyridoxine – to support barrier function and immune regulation and reduce inflammation

• Dietary modifications – removing inflammatory triggers (gluten-free, dairy-free, corn-free)

• Gut healing & microbiome balance support – addressing the gut-skin connection & microbiome health

The Results

The transformation was remarkable—and rapid:

• Day 1: Severe erythema, scaling, and excoriations

• Day 4: Visible reduction in redness and inflammation

• Day 7: Continued healing, skin texture improving

• Day 14: Near-complete resolution—smooth, healthy skin

By November 2020 to February 2022, this child went from severe, widespread eczema to being completely FREE from eczema. The before-and-after images of the inner arm and ankle show what's possible when we address root causes. Watch this patient's story HERE.

Why This Matters

What strikes me most about this case is not just the dramatic improvement, but the sustainability of the results. This child didn't need ongoing topical steroids. There was no rebound flaring. The skin healed—and stayed healed.

This is the difference between suppressing inflammation and actually resolving it. Clinical research supports what we saw in this case. Studies show that topical vitamin B12 can achieve up to 77.6% reduction in SCORAD scores, and vitamin D supplementation significantly reduces eczema severity in children. [5][11] When we combine these evidence-based topicals with dietary and lifestyle modifications that address underlying triggers, we create the conditions for true healing.

Are Alternative Topicals Right For You?

Based on my clinical experience, alternative topicals are particularly well-suited for:

Steroid-Sparing Candidates

• Children and infants where minimizing steroid exposure is especially important

• Patients with mild-to-moderate eczema seeking effective control without corticosteroids

• Those requiring treatment on sensitive areas (face, eyelids, skin folds) where steroid atrophy is a concern

Long-Term Management

• Patients needing maintenance therapy who want to avoid continuous medication use

• Those experiencing the apply-improve-stop-flare cycle with conventional treatments

• Anyone seeking lasting relief rather than temporary symptom suppression

Specific Clinical Presentations

• Malassezia-associated eczema, particularly head and neck predominant disease

• Patients with evidence of barrier dysfunction or filaggrin deficiency

• Those who have failed or cannot tolerate conventional treatments

Patient Preference

• Patients with steroid phobia or concerns about topical steroid withdrawal

• Families seeking root-cause approaches rather than symptom suppression

• Those interested in integrative or functional medicine approaches

Take the Next Step

Book an Eczema Clarity Visit to discuss your unique situation and determine if a customized compounded formulation could help you achieve lasting relief from eczema symptoms.

During your visit, we'll review your history, assess your skin, and develop a personalized treatment plan that may include these alternative topical treatments when appropriate. Together, we can work toward healthier skin without the concerns associated with long-term steroid use.

We're Going Live!

We are going live to discuss this topic on Sunday, March 1 at 4:30 pm PST! Watch the live or check out the replay here:

https://www.youtube.com/watch?v=zzgpJNl2P1w

About the Author:

Dr. Diane Angela Fong, ND, is the CEO and founder of Cleanbody, a wellness company dedicated to treating and preventing chronic disease. She is the creator of the Cleanbody Method, which follows a three-step process: Evaluate (digging into the root causes of chronic disease using lab testing and other evaluation tools), Optimize (enhancing health foundations by addressing nutrition, lifestyle, and toxic exposures), and Support (optimizing organ functions through healing protocols).

References

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2. Chu DK, Chu AWL, Rayner DG, et al. Topical Treatments for Atopic Dermatitis (Eczema): Systematic Review and Network Meta-Analysis of Randomized Trials. The Journal of Allergy and Clinical Immunology. 2023;152(6):1493-1519.

3. Maarouf M, Vaughn AR, Shi VY. Topical Micronutrients in Atopic Dermatitis-an Evidence-Based Review. Dermatologic Therapy. 2018;31(5):e12659.

4. Shin H, Kwon OS, Won CH, et al. Clinical Efficacies of Topical Agents for the Treatment of Seborrheic Dermatitis of the Scalp: A Comparative Study. The Journal of Dermatology. 2009;36(3):131-7.

5. Kim MJ, Kim SN, Lee YW, Choe YB, Ahn KJ. Vitamin D Status and Efficacy of Vitamin D Supplementation in Atopic Dermatitis: A Systematic Review and Meta-Analysis. Nutrients. 2016;8(12):E789.

6. Zhu Z, Yang Z, Wang C, Liu H. Assessment of the Effectiveness of Vitamin Supplement in Treating Eczema: A Systematic Review and Meta-Analysis. Evidence-Based Complementary and Alternative Medicine. 2019;2019:6956034.

7. Umehara Y, Trujillo-Paez JV, Yue H, et al. Calcitriol, an Active Form of Vitamin D3, Mitigates Skin Barrier Dysfunction in Atopic Dermatitis NC/Nga Mice. International Journal of Molecular Sciences. 2023;24(11):9347.

8. Alosaimi NS, Sattar Ahmad MAA, Alkreathy HM, Ali AS, Khan LM. Pharmacological Basis of the Putative Therapeutic Effect of Topical Vitamin D3 on the Experimental Model of Atopic Dermatitis in Mice. European Review for Medical and Pharmacological Sciences. 2022;26(18):6827-6836.

9. Li M, Hener P, Zhang Z, et al. Topical Vitamin D3 and Low-Calcemic Analogs Induce Thymic Stromal Lymphopoietin in Mouse Keratinocytes and Trigger an Atopic Dermatitis. Proceedings of the National Academy of Sciences of the United States of America. 2006;103(31):11736-41.

10. Pacheco-Gonzalez RM, Garcia-Marcos PW, Garcia-Marcos L. Vitamin D and Atopic Dermatitis. Mini Reviews in Medicinal Chemistry. 2015;15(11):927-34.

11. Stücker M, Pieck C, Stoerb C, et al. Topical Vitamin B12--a New Therapeutic Approach in Atopic Dermatitis-Evaluation of Efficacy and Tolerability in a Randomized Placebo-Controlled Multicentre Clinical Trial. The British Journal of Dermatology. 2004;150(5):977-83.

12. Fujishiro M, Yahagi S, Takemi S, et al. Pyridoxine Stimulates Filaggrin Production in Human Epidermal Keratinocytes. Molecular Biology Reports. 2021;48(7):5513-5518.

13. Mizutani T, Yamawaki Y, Okano Y, Masaki H. Pyridoxine (VB6) Restores the Down-Regulation of Serine Palmitoyltransferase mRNA Expression in Keratinocytes Cultured in Highly Oxidative Conditions Through Enhancement of the Intracellular Antioxidant System. Experimental Dermatology. 2019;28 Suppl 1:43-49.

14. Mabin DC, Hollis S, Lockwood J, David TJ. Pyridoxine in Atopic Dermatitis. The British Journal of Dermatology. 1995;133(5):764-7.

15. Wohlrab J, Kreft D. Niacinamide - Mechanisms of Action and Its Topical Use in Dermatology. Skin Pharmacology and Physiology. 2014;27(6):311-5.

16. Grange PA, Raingeaud J, Calvez V, Dupin N. Nicotinamide Inhibits Propionibacterium Acnes-Induced IL-8 Production in Keratinocytes Through the NF-kappaB and MAPK Pathways. Journal of Dermatological Science. 2009;56(2):106-12.

17. Mohammed D, Crowther JM, Matts PJ, Hadgraft J, Lane ME. Influence of Niacinamide Containing Formulations on the Molecular and Biophysical Properties of the Stratum Corneum. International Journal of Pharmaceutics. 2013;441(1-2):192-201.

18. Zhu JR, Wang J, Wang SS. A Single-Center, Randomized, Controlled Study on the Efficacy of Niacinamide-Containing Body Emollients Combined With Cleansing Gel in the Treatment of Mild Atopic Dermatitis. Skin Research and Technology. 2023;29(9):e13475.

19. Soma Y, Kashima M, Imaizumi A, et al. Moisturizing Effects of Topical Nicotinamide on Atopic Dry Skin. International Journal of Dermatology. 2005;44(3):197-202.

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21. Bigliardi PL, Stammer H, Jost G, et al. Treatment of Pruritus With Topically Applied Opiate Receptor Antagonist. Journal of the American Academy of Dermatology. 2007;56(6):979-88.

Disclaimer: The information provided in this blog post is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical condition or treatment and before undertaking a new health care regimen. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

Please note that due to state and federal regulations governing compounded medications, I am only able to provide these customized topical formulations to patients located in California. If you are located outside California and are interested in exploring these alternative treatments, I am happy to assist you in finding a qualified practitioner in your area who may be able to compound similar formulations for you.