What are the recommended treatment guidelines for an adult with atopic dermatitis of the axillae and winter‑related painful hand fissuring that occurs from October to April after relocating to Poland?

Treatment Guidelines for Atopic Dermatitis (Armpits) and Winter-Related Hand Fissuring

Start with aggressive emollient therapy and topical anti-inflammatory agents for both conditions, using mid-to-high potency topical corticosteroids for the axillae and barrier repair strategies for the hands, with consideration of topical JAK inhibitors or PDE-4 inhibitors if initial therapy fails.

Axillary Atopic Dermatitis Management

First-Line Topical Therapy

The 2024 AAD guidelines make strong recommendations for topical corticosteroids (TCS), topical calcineurin inhibitors (TCIs), topical JAK inhibitors, and topical PDE-4 inhibitors for atopic dermatitis 1. For intertriginous areas like the armpits:

• Use mid-potency TCS initially (avoid high-potency long-term due to skin atrophy risk in occluded areas)
• Switch to TCIs (tacrolimus or pimecrolimus) for maintenance therapy to avoid steroid-related side effects in thin-skinned areas
• Consider topical JAK inhibitors (ruxolitinib) or PDE-4 inhibitors (roflumilast, crisaborole) as steroid-sparing alternatives 2, 3

Maintenance Strategy

Apply topical anti-inflammatory therapy proactively to previously affected areas 2-3 times weekly to prevent flares, rather than waiting for inflammation to recur 4. This proactive approach reduces the need for rescue therapy with higher-potency agents.

When to Escalate

If axillary AD remains uncontrolled despite optimized topical therapy, the 2024 guidelines provide strong recommendations for systemic biologics (dupilumab, tralokinumab, lebrikizumab) or oral JAK inhibitors (abrocitinib, baricitinib, upadacitinib) 1, 3. Dupilumab has the longest safety track record and should be considered first among biologics.

Winter-Related Hand Fissuring (October-April in Poland)

Clinical Context

Your seasonal pattern (October-April, Poland but not Norway) strongly suggests irritant contact dermatitis exacerbated by low humidity and cold weather, potentially overlapping with atopic hand dermatitis given your axillary AD 5, 6.

Aggressive Barrier Protection Protocol

This is the cornerstone of management and must be implemented before pharmacologic therapy:

• Apply thick emollients (ointment-based, not lotion) immediately after hand washing and reapply every 2-3 hours
• Use cotton gloves under vinyl/nitrile gloves for wet work to prevent irritant exposure
• Apply emollients before bed and wear cotton gloves overnight for occlusive therapy
• Avoid hot water, harsh soaps, and alcohol-based sanitizers when possible

Topical Anti-Inflammatory Therapy for Hands

For active fissuring and inflammation:

• High-potency TCS (clobetasol propionate 0.05%) for 2 weeks to rapidly control inflammation and promote healing of fissures 2
• Transition to mid-potency TCS or TCIs for maintenance once fissures heal
• Consider topical JAK inhibitors (ruxolitinib cream) as a steroid-sparing option, particularly effective for hand dermatitis 3, 7

Systemic Therapy Consideration

If hand dermatitis causes significant functional impairment or quality of life impact despite optimized topical therapy, dupilumab is FDA-approved for moderate-to-severe atopic dermatitis and has shown efficacy for atopic hand dermatitis 6. This would simultaneously treat both your axillary and hand involvement.

Practical Treatment Algorithm

Step 1: Foundation (Start Immediately)

• Intensive emollient therapy: Apply ointment-based moisturizers 4-6 times daily to hands, after every hand wash
• Barrier protection: Cotton gloves under protective gloves for all wet work
• Environmental modification: Use humidifiers indoors during Polish winter months

Step 2: Active Treatment Phase (Weeks 1-4)

• Armpits: Mid-potency TCS twice daily for 2 weeks, then switch to tacrolimus 0.1% ointment twice daily
• Hands: High-potency TCS (clobetasol) twice daily for 2 weeks to heal fissures, with continued aggressive emollients

Step 3: Maintenance Phase (Ongoing)

• Armpits: Tacrolimus 0.1% ointment 2-3 times weekly proactively to previously affected areas
• Hands: Mid-potency TCS or tacrolimus as needed, with continued barrier protection and emollients
• Both areas: Daily emollient use year-round, intensified October-April

Step 4: Escalation (If Steps 1-3 Fail After 8-12 Weeks)

• Consider topical JAK inhibitor (ruxolitinib cream) for both sites as next step 3
• If quality of life remains significantly impaired, initiate dupilumab (strong recommendation, treats both sites systemically) 1, 3

Critical Pitfalls to Avoid

Do not use systemic corticosteroids - the 2024 guidelines make a conditional recommendation against their use due to rebound flares and long-term adverse effects 1.

Do not rely on oral antihistamines - they provide minimal benefit for AD pruritus and are not recommended as primary therapy 8.

Do not use topical antimicrobials or antiseptics routinely - conditional recommendation against unless clear secondary infection is present 2, 9.

Do not underestimate the importance of emollients - they are foundational therapy with a strong recommendation, not optional 2, 9.

Alternative Diagnosis Consideration

If treatment fails, consider patch testing to rule out allergic contact dermatitis, which can coexist with or mimic AD 1, 6. The seasonal pattern and hand involvement make occupational or environmental allergen exposure possible.