Eczema and Psoriasis: medications and paying cash

Overview

Atopic dermatitis, a long-term form of eczema, causes intensely itchy, dry, scaly rashes; it often starts in infancy, runs in families alongside asthma and hay fever, scratching can leave raw or thickened skin, and skin infections can develop easily. Psoriasis is a long-lasting disease in which an overactive immune system makes skin cells multiply too quickly, producing thick, red patches with silvery-white scales that itch or burn; it can also affect the nails and, as psoriatic arthritis, the joints, and it is linked with heart attacks and strokes, diabetes, anxiety and depression. Psoriasis has no cure, but treatment keeps symptoms under control; for both conditions the plan depends on type, severity and where the skin is affected.

Moisturizer applied right after bathing is the basis of eczema care, and topical corticosteroids are the main prescription treatment for both conditions. They range from hydrocortisone, sold over the counter, through medium-potency products such as mometasone, to high and super-high-potency products such as fluocinonide, augmented betamethasone dipropionate and clobetasol. Clobetasol and the other super-high-potency products are limited to a couple of weeks for most forms and a set weekly amount, and are kept off the face, groin and underarms, where even short use can thin the skin. For eczema, a mild steroid is usually tried first. Children absorb more for their size, so they get the least amount that works, and the labels for the super-high-potency products set age limits (most are not recommended under 12, augmented betamethasone under 13, and the clobetasol lotion, spray and shampoo under 18). Tacrolimus ointment and pimecrolimus cream, the topical calcineurin inhibitors, are non-steroid second-line options for eczema from age two; they carry a boxed warning about rare reports of skin cancer and lymphoma, so they go on affected skin only, in short courses. Calcipotriene, a vitamin D analog, and tazarotene, a retinoid, treat plaque psoriasis; tazarotene must not be used in pregnancy, and people who can become pregnant are advised to have a negative pregnancy test within two weeks before starting and to use effective birth control during treatment.

When creams are not enough, treatment moves to light therapy or medicines that act on the whole body. Methotrexate, a generic tablet for severe psoriasis, is taken once a week, never daily: people who mistakenly took it daily have had severe side effects or died, so ask the pharmacist to confirm that the label says once weekly; folic acid is usually given alongside, blood counts and liver and kidney tests are checked regularly, and it must not be used in pregnancy. Apremilast, a tablet for plaque psoriasis and psoriatic arthritis, can cause diarrhea, nausea, weight loss and depressed mood. Crisaborole, a non-steroid ointment, treats mild to moderate eczema, and the eczema biologics such as dupilumab injections, for moderate to severe eczema, are brand-only specialty products, while several psoriasis biologics have biosimilars.

Choosing between the options when you pay cash

Almost every topical in this group is a generic: the corticosteroids, tacrolimus ointment, pimecrolimus cream, calcipotriene cream, ointment and scalp solution, and tazarotene cream and gel, and quotes for the same tube can differ between pharmacies. A quote covers exactly the product written: cream, ointment, gel, lotion, foam, solution and shampoo are separate products, as are regular and augmented betamethasone and the two strengths of fluocinonide, and a pharmacist cannot swap one for another without the prescriber. Foams, sprays and shampoos have fewer makers than creams and ointments, and if the prescriber allows either a cream or an ointment, ask for quotes on both; for eczema moisturizers, NIAMS advises creams and ointments over lotions with a high water or alcohol content, which can burn. Tube size drives the quote too, so ask for the size that fits the area and the course.

Methotrexate tablets are a plain generic, and because the dose is weekly the tablet count for a ninety-day supply depends on the dose and strength written, so ask the pharmacist; Trexall, the oral solutions and the autoinjector are separate brand products. Generic apremilast tablets have been approved but may not yet be on pharmacy shelves, so ask; Otezla XR has none. For dupilumab and the other biologics, check the plan’s coverage and the maker’s program first.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Hydrocortisone
  Cream and ointment (prescription), plus over-the-counter products, Lotion, solution and spray, Hydrocortisone butyrate cream and solution
  Generic: Yes · Four times a day
• Triamcinolone
  Cream, Ointment, Lotion
  Generic: Yes · Two or three times a day
• Mometasone Furoate
  Cream, ointment and lotion, Nasal spray (prescription generic), Nasal spray (over the counter)
  Generic: Yes · Once a day
• Fluocinonide
  Cream, 0.05 percent and 0.1 percent, Emollient (emulsified base) cream, Ointment
  Generic: Yes · See the guide
• Betamethasone Dipropionate
  Cream and ointment (regular and augmented), Lotion (regular and augmented), Gel (augmented)
  Generic: Yes · Once or twice a day
• Clobetasol Propionate
  Cream and emollient cream, Ointment, Gel
  Generic: Yes · Twice a day
• Tacrolimus
  Capsules (Prograf and generic), Extended-release tablets (Envarsus XR), Extended-release capsules (Astagraf XL and generic)
  Generic: Yes · Every 12 hours
• Pimecrolimus
  Cream
  Generic: Yes · Twice a day
• Calcipotriene
  Cream (Dovonex and generic), Ointment (Dovonex, and generic including Calcitrene), Scalp solution (generic)
  Generic: Yes · See the guide
• Tazarotene
  Cream (Tazorac and generic), Gel (Tazorac and generic), Lotion (Arazlo)
  Generic: Yes · Once a day
• Methotrexate
  Tablets (generic and Trexall), Oral solution (Xatmep and Jylamvo), Single-dose autoinjector for use under the skin (Rasuvo)
  Generic: Yes · See the guide
• Apremilast
  Tablets (Otezla), Extended-release tablets (Otezla XR), 28-day starter packs
  Generic: No · Twice a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• How strong is this steroid, how much can I use in a week, and for how long?
• Where on my body should I keep it off, and can I cover the area?
• Would the cream or the ointment suit me, and which tube size fits?
• If I take methotrexate, which day is my dose, and what blood tests do I need?
• Is this safe if I am pregnant, could become pregnant or am breastfeeding?

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