What is the diagnosis and treatment for atopic dermatitis (atopic eczema)?

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 more severe or widespread disease, substantially impaired quality of life, or refractory to optimized topical therapy. The goal of treatment is to achieve disease control, reduce symptoms, and improve quality of life. According to the most recent guidelines 1, the decision to initiate phototherapy or systemic therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of atopic dermatitis, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions.

For daily management, applying a thick, fragrance-free moisturizer like CeraVe, Vanicream, or Eucerin at least twice daily, especially after bathing while skin is still damp, is recommended. For mild to moderate flares, using a topical corticosteroid such as hydrocortisone 1% for the face and triamcinolone 0.1% for the body, applying a thin layer to affected areas twice daily for 7-14 days, can be effective. Avoiding known triggers, including harsh soaps, fragrances, certain fabrics like wool, stress, and allergens, is also crucial. Taking short, lukewarm showers (under 10 minutes) and patting skin dry rather than rubbing can help reduce irritation.

For severe cases, prescription medications like topical calcineurin inhibitors (tacrolimus, pimecrolimus), PDE4 inhibitors (crisaborole), or systemic medications such as dupilumab may be necessary 1. These treatments work by reducing inflammation and repairing the skin barrier, which is fundamentally impaired in atopic dermatitis, allowing moisture loss and allergen penetration that perpetuate the itch-scratch cycle. The use of phototherapy and systemic therapies should be considered for patients with moderate-to-severe atopic dermatitis that does not respond to topical therapy and for which phototherapy is not a viable option 1.

Key considerations in the management of atopic dermatitis include:

• Using emollients and prescription topical therapies as first-line treatment
• Considering phototherapy and systemic therapies for more severe or widespread disease
• Avoiding known triggers and irritants
• Using shared decision-making between patients and clinicians to determine the best course of treatment
• Monitoring for potential side effects and adjusting treatment as needed.

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 A total of 403 pediatric patients 2-17 years old were included in the studies. 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.

Atopic Dermatitis Treatment with Pimecrolimus (TOP)

• Pimecrolimus cream is used to treat mild to moderate atopic dermatitis in patients 2 years and older.
• Clinical studies have shown that 35% of patients treated with pimecrolimus cream were clear or almost clear of signs of atopic dermatitis, compared to 18% of vehicle-treated patients 2.
• The improvement in atopic dermatitis occurred in conjunction with a reduction in pruritus.
• Pimecrolimus cream should be used only on areas of skin that have eczema, and for short periods, with breaks in between if needed 2.

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 of Atopic Dermatitis

• 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.
• 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 Non-Steroid Therapies for Atopic Dermatitis

• Topical calcineurin inhibitors, such as pimecrolimus and tacrolimus, provide a safe and effective alternative to topical corticosteroid use in the treatment of atopic dermatitis 5, 6.
• Phosphodiesterase 4 (PDE4) inhibitors, such as crisaborole, have shown efficacy and safety in clinical trials 6.
• These topical non-steroid therapies have low systemic absorption and are associated with low risk of systemic adverse events or malignancy 6.

Future Directions in Atopic Dermatitis Treatment

• Novel therapies are currently under investigation, with the hope of shifting the paradigm of AD management from symptom control to disease eradication 7.
• 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 3.