What are the treatments for atopic dermatitis (atopic eczema)?

From the Guidelines

Atopic dermatitis treatment should prioritize a multi-faceted approach focusing on skin hydration, inflammation control, and trigger avoidance, with emollients and prescription topical therapies being sufficient for most people, while those with more severe cases may require phototherapy or systemic therapies, as recommended by the American Academy of Dermatology guidelines 1. The treatment approach for atopic dermatitis involves several key components, including:

• Daily moisturizing with fragrance-free emollients like CeraVe, Eucerin, or Vanicream, applied immediately after bathing to lock in moisture
• Topical corticosteroids, such as hydrocortisone 1% for the face and triamcinolone 0.1% for the body, for mild flares, applied twice daily for 7-14 days
• Medium-potency steroids like mometasone furoate 0.1% or stronger options under medical supervision for more severe cases
• Topical calcineurin inhibitors, such as tacrolimus 0.03-0.1% or pimecrolimus 1%, as steroid-free alternatives for sensitive areas like the face and skin folds
• Prescription options, including dupilumab (300mg subcutaneous injection every two weeks), oral immunosuppressants like cyclosporine (3-5mg/kg/day), or phototherapy, for moderate-to-severe cases, as supported by the guidelines 1 Non-pharmacological measures are also crucial, including:
• Lukewarm showers under 10 minutes
• Gentle fragrance-free cleansers
• Cotton clothing
• Avoiding known triggers, such as certain foods, dust mites, and pet dander
• Maintaining optimal humidity levels (40-50%) These treatments work by repairing the skin barrier, reducing inflammation, and minimizing the itch-scratch cycle that characterizes atopic dermatitis, ultimately improving disease control and quality of life, as emphasized by the guidelines 1.

From the FDA Drug Label

DUPIXENT is indicated for the treatment of adult and pediatric patients aged 6 months and older with moderate-to-severe atopic dermatitis (AD) whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. ELIDEL Cream should be used only on areas of skin that have eczema. The treatments for atopic dermatitis include:

• Dupilumab (SQ): indicated for the treatment of adult and pediatric patients aged 6 months and older with moderate-to-severe atopic dermatitis (AD) whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.
• Pimecrolimus (TOP): should be used only on areas of skin that have eczema, and is not for use on a child under 2 years old 2. Key considerations:
• Dupilumab can be used with or without topical corticosteroids 3.
• Pimecrolimus should be avoided on malignant or pre-malignant skin conditions, and its safety has not been established in patients with generalized erythroderma 2.

From the Research

Treatment Options for Atopic Dermatitis

• The objectives of therapy for atopic dermatitis are to reduce skin inflammation and pruritus, restore skin barrier function, and improve quality of life (QoL) 4.
• Treatments can be classified as moisturizing and basic care, topical therapy, phototherapy, and systemic therapy 4.
• Topical corticosteroids have been the pillar of medicated therapy for atopic dermatitis since their introduction nearly 50 years ago 5.
• Topical calcineurin inhibitors provide targeted anti-inflammatory activity without the local or systemic side-effects seen with topical corticosteroids 5.
• Emollients have long been used to maintain the skin barrier function in patients with atopic dermatitis 5.
• A multi-therapeutic approach that incorporates short-term management of flares and longer-term strategies to prolong the time between flares is needed for the treatment of atopic dermatitis 5.

Systemic Therapies for Atopic Dermatitis

• Systemic corticosteroids should generally be avoided but can be used rarely for severe atopic dermatitis under certain circumstances, including a lack of other treatment options, as a bridge to other systemic therapies or phototherapy, during acute flares in need of immediate relief, in anticipation of a major life event or in the most severe cases 6.
• If used, treatment with systemic corticosteroids should be limited to the short term 6.
• NBUVB, mycophenolate, and methotrexate remain the reasonable first-line systemic treatment options for atopic dermatitis 7.
• A brief run-in with high-dose cyclosporine to clear atopic dermatitis followed by maintenance with low-dose cyclosporine or cellcept - both of which have better risk and benefit ratios is a reasonable approach 7.

Topical Therapies for Atopic Dermatitis

• Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups 8.
• Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment 8.
• Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 8.
• Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients 8.