What is the diagnosis and treatment for Atopic Dermatitis (AD)?

From the Guidelines

Atopic dermatitis management should prioritize the use of emollients and prescription topical therapies for most patients, with phototherapy and systemic therapies considered for those with severe or widespread disease, substantially impaired quality of life, or refractory to optimized topical therapy, as recommended by the 2024 American Academy of Dermatology guidelines 1.

Key Considerations

• For daily management, gentle fragrance-free cleansers and thick moisturizers like CeraVe, Vanicream, or Eucerin should be applied at least twice daily, especially after bathing while skin is still damp.
• Mild flares can be treated with low-potency topical corticosteroids such as hydrocortisone 1% cream twice daily for 1-2 weeks.
• Moderate to severe cases may require medium to high-potency steroids like triamcinolone 0.1% or fluocinonide 0.05% for short periods, followed by a taper to prevent skin thinning.
• Non-steroidal alternatives include tacrolimus (Protopic) or pimecrolimus (Elidel) for sensitive areas like the face.
• Severe cases might need systemic treatments such as dupilumab (Dupixent) injections or oral immunosuppressants, with dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib supported by strong recommendations for use in adults with atopic dermatitis 1.

Prevention of Flares

• Identify and avoid triggers like harsh soaps, wool clothing, stress, and certain foods.
• Take short, lukewarm showers.
• Use a humidifier in dry environments.
• Wear cotton clothing.

Underlying Pathophysiology

• Atopic dermatitis results from a combination of genetic factors affecting skin barrier function and immune system dysregulation, making the skin more susceptible to irritants and allergens while triggering inflammation, as noted in the updated guidelines for the management of atopic dermatitis in adults with phototherapy and systemic therapies 1.

From the FDA Drug Label

CLINICAL STUDIES Three randomized, double-blind, vehicle-controlled, multi-center, Phase 3 studies were conducted in 589 pediatric patients ages 3 months-17 years old to evaluate ELIDEL ® (pimecrolimus) Cream 1% for the treatment of mild to moderate atopic dermatitis Two of the three trials support the use of ELIDEL Cream in patients 2 years and older with mild to moderate atopic dermatitis At endpoint, based on the physician’s global evaluation of clinical response, 35% of patients treated with ELIDEL Cream were clear or almost clear of signs of atopic dermatitis compared to only 18% of vehicle-treated patients.

Pimecrolimus (TOP) Cream 1% is effective in the treatment of mild to moderate atopic dermatitis in patients 2 years and older, with 35% of patients achieving clear or almost clear skin after 6 weeks of treatment, compared to 18% of vehicle-treated patients 2.

• Key benefits include:
  • Reduction in erythema and infiltration/papulation by day 8
  • Improvement in pruritus by 6 weeks
  • Significant treatment effect seen by day 15 in two pediatric studies.

From the Research

Definition and Causes of Atopic Dermatitis

• Atopic dermatitis (atopic eczema) is a chronic relapsing and remitting inflammatory skin disease affecting one in 10 people in their lifetime 3
• It is caused by a complex interaction of immune dysregulation, epidermal gene mutations, and environmental factors that disrupts the epidermis causing intensely pruritic skin lesions 3

Diagnosis and Treatment

• The American Academy of Dermatology has created simple diagnostic criteria based on symptoms and physical examination findings 3
• Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers 3
• Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups 3, 4
• Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment 3, 5, 6, 7
• Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 3
• Antistaphylococcal antibiotics are effective in treating secondary skin infections 3
• Oral antihistamines are not recommended because they do not reduce pruritus 3

Topical Corticosteroids

• Topical corticosteroids are classified by strength and the risk of adverse effects such as atrophy, striae, rosacea, telangiectasias, purpura, and other cutaneous and systemic reactions 4
• The risk of adverse effects increases with prolonged use, a large area of application, higher potency, occlusion, and application to areas of thinner skin such as the face and genitals 4
• When prescribing topical corticosteroids for use in children, lower potencies and shorter durations should be used 4

Topical Calcineurin Inhibitors

• Tacrolimus ointment (in its 2 manufactured strengths of 0.1% and 0.03%) might be an alternative treatment to topical corticosteroids 5
• Tacrolimus 0.1% was better than low-potency corticosteroids, pimecrolimus 1%, and tacrolimus 0.03% 5
• Tacrolimus 0.03% was superior to mild corticosteroids and pimecrolimus 5
• Both tacrolimus formulations seemed to be safe, and no evidence was found to support the possible increased risk of malignancies or skin atrophy with their use 5, 6

Other Treatments

• Crisaborole and dupilumab are newer medications approved by the U.S Food and Drug Administration, but are currently cost prohibitive for most patients 3
• Phosphodiesterase 4 (PDE4) inhibitors have shown efficacy and safety in studies up to one year 6
• Topical antibiotics alone or in combination may be among the least effective treatments 7