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Beyond Steroids: Alternative Topical Treatments That Address the Root Causes of Eczema
- Dr. Diane Angela Fong, ND
- 19 hours ago
- 14 min read
By Diane Angela Fong. ND
Atopic dermatitis affects millions of patients worldwide, with inflammation and relentless itching being the most distressing symptoms. While topical corticosteroids remain the conventional first-line treatment, growing evidence supports alternative topical treatments that may not only control symptoms but address underlying causes—offering lasting relief without the concerns associated with long-term steroid use.
In my clinical practice, I’ve seen meaningful improvements using targeted, steroid-sparing topicals such as zinc pyrithione, vitamin D, vitamin B12, and other integrative alternatives. These therapies are designed to address several key drivers of eczema at once — including microbial imbalance, skin barrier dysfunction, and immune dysregulation — rather than simply suppressing inflammation.
What makes these approaches different is that they support ongoing skin repair and regulation, which can lead to continued improvement even after the topical is discontinued — something conventional anti-inflammatory medications often struggle to achieve.
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
The Problem with Long-Term Topical Corticosteroids
Topical corticosteroids are highly effective for controlling acute eczema flares and remain strongly recommended when symptoms cannot be controlled with moisturizers alone.[1] However, they work primarily by suppressing inflammation without addressing the underlying factors that perpetuate the disease.
Patients treated with topical steroids often show clinical aggravation after treatment cessation, requiring continuous or repeated use to maintain control. While short-term use appears safe, longer-term use has been associated with local side effects including skin atrophy, striae, telangiectasias, and dyspigmentation.[2] High-potency topical corticosteroids should be applied for less than 4 continuous weeks at a time, with particular caution on sensitive areas including the face, skin folds, and groin.[1]
Understanding Topical Steroid Withdrawal
An increasing number of patients express skepticism towards glucocorticosteroids, partly due to concerns about topical steroid withdrawal (also called topical steroid addiction or red skin syndrome).[3] While this phenomenon remains controversial in the medical literature, patients report experiencing:
Burning, stinging sensations when steroids are discontinued
Rebound flaring that may be more severe than the original eczema
Skin redness and sensitivity that can persist for months
Psychological distress from the withdrawal process
Lengthy steroid use can lead to topical corticosteroid withdrawal with burning, stinging, and erythema, though this potential side effect remains controversial with overall low evidence levels.[3] These concerns contribute to steroid phobia and poor adherence to conventional treatment regimens—making alternative options increasingly valuable.
The Calcineurin Inhibitor Controversy
Topical calcineurin inhibitors (tacrolimus and pimecrolimus) are effective alternatives that cause no thinning of the skin.[4] Network meta-analyses show that pimecrolimus and tacrolimus are among the most effective treatments for improving and maintaining multiple atopic dermatitis outcomes.[3][5]
However, topical calcineurin inhibitors have important limitations:
Higher cost compared to topical corticosteroids[6]
More adverse reactions, particularly initial skin irritation including burning and pruritus, primarily in the first few days of use[3][7]
FDA black box warning associating them with cancer risk, based on animal studies of excessive systemic dosing and isolated reports of melanoma and lymphoma in adults using these medications[7-8]
While there is currently no evidence of increased lymphoma incidence in large, prospective longitudinal cohorts and meta-analyses, and no sufficient evidence that topical calcineurin inhibitors induce clinically relevant immunosuppression, the black box warning creates patient anxiety and limits acceptance.[3]
Alternative Topical #1: Zinc Pyrithione—Addressing the Root Cause
Why Zinc Pyrithione Fixes the Root Problem
Emerging research suggests that microbial dysbiosis, particularly Malassezia overgrowth, plays a fundamental role in perpetuating eczema. Malassezia is a yeast that naturally lives on skin but can overgrow and trigger inflammatory responses that worsen eczema symptoms. Seborrheic dermatitis, a form of eczema, is recognized as a multi-factorial disease driven by microbial dysbiosis, primarily involving Malassezia yeast.[9]
This is where zinc pyrithione becomes transformative. Rather than simply suppressing inflammation, zinc pyrithione addresses the underlying microbial imbalance that drives chronic eczema.
Zinc pyrithione works through multiple therapeutic pathways:
Broad antimicrobial activity: Effective against fungi, gram-positive and gram-negative bacteria, with an average in vitro minimum inhibitory concentration of 10-15 ppm against the most abundant skin Malassezia species[9]
Anti-inflammatory effects: Zinc provides immune-modulating benefits beyond its antifungal properties; magnesium, zinc, and iodine all appear to improve atopic dermatitis through anti-inflammatory and anti-microbial effects[10]
Slow-release reservoir: Particles deposited on skin continue releasing active material for extended benefits, providing persistent therapeutic effects[11]
Addressing the root cause: By normalizing the skin microbiome, zinc pyrithione helps restore the skin's natural balance
The Evidence for Lasting Relief
What makes zinc pyrithione particularly compelling is its unique ability to provide prolonged remission. In my clinical experience, patients treated with zinc pyrithione show continuous improvement even after stopping treatment—a stark contrast to those treated with topical steroids or tacrolimus, who often experience clinical aggravation after treatment cessation.
Zinc pyrithione is one of the most widely used ingredients worldwide in medicated products for treating dandruff and seborrheic dermatitis.[9] Its success as a topical therapeutic is underscored by the way it balances treatment efficacy with formulation safety.[11] Future research is expected to yield further advances in zinc pyrithione formulations and include re-purposing towards a range of other dermatologic applications, which is likely to have significant clinical impact.[9]
Additionally, systematic reviews have found that zinc supplementation may be of benefit in the treatment plan for atopic dermatitis, with lower serum, hair, and erythrocyte zinc levels associated with atopic dermatitis.[12-13]
Alternative Topical #2: Vitamin D To Support 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.[17]
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
Suppressing Th2/Th17 responses while enhancing regulatory T cell development[18]
Inducing antimicrobial peptides that help control skin microbiome dysbiosis[19]
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.[14]
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.[15]
Important Considerations
Early research raised concerns that certain topical vitamin D analogs might exacerbate symptoms by inducing TSLP expression in keratinocytes.[16] However, more recent evidence indicates that formulation and vehicle matter significantly. When compounded at appropriate concentrations in suitable bases like Xematop, 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—the zinc addresses microbial dysbiosis while vitamin D supports barrier repair and immune regulation. This combination has produced excellent results in my pediatric patients, as demonstrated in the case study above where topical vitamin D and B12 contributed to dramatic improvement within just two weeks.
Alternative Topical #3: Vitamin B12 Provides Evidence-Based Symptom Relief
Strong Clinical Evidence
Topical vitamin B12 has robust clinical evidence supporting its use in atopic dermatitis, with particularly pronounced antipruritic (anti-itch) effects. A meta-analysis found that topical vitamin B12 significantly decreased eczema severity scores.[23]
Key clinical trials demonstrate impressive results:
In a randomized, placebo-controlled multicentre trial of 49 patients, the modified Six Area Six Sign Atopic Dermatitis score dropped to a significantly greater extent on the vitamin B12-treated side compared to placebo. At the conclusion of the study, 58% of investigators and 59% of patients rated the active drug as "good" or "very good."[24]
A randomized, left-to-right comparative trial found that vitamin B12-barrier cream achieved a 77.6% SCORAD index reduction versus 33.5% with standard glycerol-petrolatum-based emollient cream at 12 weeks.[25]
In a pediatric study of 21 children (ages 6 months to 18 years), skin treated with topical vitamin B12 improved significantly more than placebo-treated skin at both 2 and 4 weeks.[26]
How It Works
Vitamin B12 (cyanocobalamin) functions as an effective scavenger of nitric oxide, which plays a role in eczema-related inflammation.[24] By reducing nitric oxide production, vitamin B12 helps decrease the pruritus and erythema characteristic of atopic dermatitis.
Importantly, the treatment was very well tolerated and involved only very low safety risks for patients.[24] This makes it an excellent option for long-term use, particularly in children where minimizing medication exposure is a priority.
The Power of Combination Therapy
Why I Combine These Ingredients
In my practice, I have found that the most effective approach combines these evidence-based ingredients to address multiple aspects of eczema pathophysiology simultaneously:
Zinc Pyrithione addresses the microbial dysbiosis that perpetuates inflammation, providing lasting relief by treating the root cause rather than just suppressing symptoms.
Vitamin D supports barrier function and immune regulation, helping the skin heal and resist future flares.
Vitamin B12 (when added) provides additional anti-inflammatory and antipruritic benefits through nitric oxide scavenging.
Xematop base serves as an optimal delivery vehicle that moisturizes while delivering the active ingredients effectively.
Additional Compounded Options I Assess in My Practice
While zinc pyrithione, vitamin D, and vitamin B12 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 severe, treatment-resistant itching, topical naltrexone offers a unique mechanism of action. Naltrexone is an opioid receptor antagonist that, when applied topically, can provide significant relief from pruritus.
A randomized, placebo-controlled, crossover trial demonstrated that 1% naltrexone cream achieved a 70% pruritus response rate in patients with atopic dermatitis.[21-22] The formulation provided rapid relief, requiring a median of only 46 minutes to reduce itch symptoms by 50%—compared to 74 minutes for placebo.[28]
The mechanism involves blocking mu-opioid receptors in the epidermis. Interestingly, histologic evidence showed that increased epidermal mu-opioid receptor expression correlated with patients who reported significant symptomatic improvement.[27] Naltrexone affects inflammation, cell adhesion, and keratinocyte proliferation and migration, making it potentially helpful for a variety of inflammatory skin conditions.[29]
Low-dose naltrexone (whether topical or oral) has demonstrated efficacy in treating dermatologic conditions with improvement in disease severity, body surface area involvement, and associated symptoms.[30] Fewer side effects have been reported with low-dose naltrexone compared to standard doses.[27]
Other Compounded Options
Depending on individual patient needs, I may also consider:
Topical ketotifen – A mast cell stabilizer that can help reduce inflammation and itching by preventing the release of histamine and other inflammatory mediators
Topical montelukast – A leukotriene receptor antagonist that may help address the inflammatory cascade in eczema
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.
Who Benefits Most
Alternative topicals are particularly valuable for:
Patients with mild-to-moderate eczema seeking effective control without corticosteroids
Children and infants where minimizing steroid exposure is especially important
Patients requiring long-term maintenance therapy who want to avoid continuous medication use
Those with Malassezia-associated eczema, particularly head and neck predominant disease
Patients with steroid phobia or concerns about topical steroid withdrawal
Anyone seeking lasting relief rather than temporary symptom suppression
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 – to support barrier function and immune regulation
Topical Vitamin B12 – to reduce inflammation through nitric oxide scavenging
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. When we combine these evidence-based topicals with dietary and lifestyle modifications that address underlying triggers, we create the conditions for true healing.
Take the Next Step
If you or your child is struggling with eczema and you're tired of the steroid cycle, know that there are alternatives. Every person is different, and what works for one may need to be adjusted for another. But this case—and many others like it in my practice—demonstrates that lasting relief is possible.
Ready to explore whether these alternative treatments are right for you? 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, February 22 at 4:30 pm PST! Watch the live or check out the replay here:
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
Atopic Dermatitis: Updated Guidelines From the AAAAI/ACAAI Joint Task Force on Practice Parameters.
Frazier W, Schneider L, Chu DK. American Family Physician. 2024;110(4):437-439.
Lax SJ, Van Vogt E, Candy B, et al. Clinical and Experimental Allergy : Journal of the British Society for Allergy and Clinical Immunology. 2024;54(12):960-972. doi:10.1111/cea.14556.
Guttman-Yassky E, Renert-Yuval Y, Brunner PM. Lancet (London, England). 2025;405(10478):583-596. doi:10.1016/S0140-6736(24)02519-4.
Optimizing Topical Management of Atopic Dermatitis.
Butala S, Paller AS. Annals of Allergy, Asthma & Immunology : Official Publication of the American College of Allergy, Asthma, & Immunology. 2022;128(5):488-504. doi:10.1016/j.anai.2022.03.004.
Chu DK, Chu AWL, Rayner DG, et al. The Journal of Allergy and Clinical Immunology. 2023;152(6):1493-1519. doi:10.1016/j.jaci.2023.08.030.
Solman L, Lloyd-Lavery A, Grindlay DJC, et al. Clinical and Experimental Dermatology. 2019;44(4):363-369. doi:10.1111/ced.13885.
Atopic Dermatitis: Update on Skin-Directed Management: Clinical Report.
Schoch JJ, Anderson KR, Jones AE, Tollefson MM. Pediatrics. 2025;:e2025071812. doi:10.1542/peds.2025-071812.
Chu DK, Schneider L, Asiniwasis RN, et al. Annals of Allergy, Asthma & Immunology : Official Publication of the American College of Allergy, Asthma, & Immunology. 2024;132(3):274-312. doi:10.1016/j.anai.2023.11.009.
Targeted Delivery of Zinc Pyrithione to Skin Epithelia.
Mangion SE, Holmes AM, Roberts MS. International Journal of Molecular Sciences. 2021;22(18):9730. doi:10.3390/ijms22189730.
Topical Micronutrients in Atopic Dermatitis-an Evidence-Based Review.
Maarouf M, Vaughn AR, Shi VY. Dermatologic Therapy. 2018;31(5):e12659. doi:10.1111/dth.12659.
Zinc Pyrithione: A Topical Antimicrobial With Complex Pharmaceutics.
Schwartz JR. Journal of Drugs in Dermatology : JDD. 2016;15(2):140-4.
Dhaliwal S, Nguyen M, Vaughn AR, et al. American Journal of Clinical Dermatology. 2020;21(1):21-39. doi:10.1007/s40257-019-00484-0.
Zinc and Atopic Dermatitis: A Systematic Review and Meta-Analysis.
Gray NA, Dhana A, Stein DJ, Khumalo NP. Journal of the European Academy of Dermatology and Venereology : JEADV. 2019;33(6):1042-1050. doi:10.1111/jdv.15524.
International Journal of Molecular Sciences. 2023. Umehara Y, Trujillo-Paez JV, Yue H, et al.
European Review for Medical and Pharmacological Sciences. 2022. Alosaimi NS, Sattar Ahmad MAA, Alkreathy HM, Ali AS, Khan LM.
Proceedings of the National Academy of Sciences of the United States of America. 2006. Li M, Hener P, Zhang Z, et al.
Nutrients. 2016. Kim MJ, Kim SN, Lee YW, Choe YB, Ahn KJ.
Vitamin D in the Prevention and Treatment of Inflammatory Skin Diseases.
International Journal of Molecular Sciences. 2025. Bukvić Mokos Z, Tomić Krsnik L, Harak K, et al.
Vitamin D in Atopic Dermatitis: Role in Disease and Skin Microbiome.
Nutrients. 2025. Blady K, Pomianowski B, Strugała M, et al.
Nutrients. 2024. Nielsen AY, Høj S, Thomsen SF, Meteran H.
Evidence-Based Complementary and Alternative Medicine : eCAM. 2019. Zhu Z, Yang Z, Wang C, Liu H.
10.
Randomized Trial of Vitamin D Supplementation for Winter-Related Atopic Dermatitis in Children.
The Journal of Allergy and Clinical Immunology. 2014. Camargo CA, Ganmaa D, Sidbury R, et al.
Zhu Z, Yang Z, Wang C, Liu H. Evidence-Based Complementary and Alternative Medicine : eCAM. 2019;2019:6956034. doi:10.1155/2019/6956034.
Stücker M, Pieck C, Stoerb C, et al. The British Journal of Dermatology. 2004;150(5):977-83. doi:10.1111/j.1365-2133.2004.05866.x.
Nistico SP, Del Duca E, Tamburi F, et al. Dermatologic Therapy. 2017;30(5). doi:10.1111/dth.12523.
Evaluation of Topical Vitamin B(12) for the Treatment of Childhood Eczema.
Januchowski R. Journal of Alternative and Complementary Medicine (New York, N.Y.). 2009;15(4):387-9. doi:10.1089/acm.2008.0497.
Ekelem C, Juhasz M, Khera P, Mesinkovska NA. JAMA Dermatology. 2019;155(2):229-236. doi:10.1001/jamadermatol.2018.4093.
Treatment of Pruritus With Topically Applied Opiate Receptor Antagonist.
Bigliardi PL, Stammer H, Jost G, et al. Journal of the American Academy of Dermatology. 2007;56(6):979-88. doi:10.1016/j.jaad.2007.01.007.
The Uses of Naltrexone in Dermatologic Conditions.
Lee B, Elston DM. Journal of the American Academy of Dermatology. 2019;80(6):1746-1752. doi:10.1016/j.jaad.2018.12.031.
Low-Dose Naltrexone for Treatment of Dermatologic Conditions: A Clinical Review.
Zhou MH, Elston DM, Morrison BW, Lipner SR. Journal of the American Academy of Dermatology. 2025;:S0190-9622(25)02812-9. doi:10.1016/j.jaad.2025.09.028.
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.
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