What are the guidelines for managing atopic dermatitis?

Clinical Guidelines for Atopic Dermatitis Management

Strong recommendations for topical therapies including moisturizers, topical corticosteroids, calcineurin inhibitors, PDE-4 inhibitors, and JAK inhibitors form the cornerstone of atopic dermatitis treatment, with systemic therapies reserved for moderate-to-severe cases unresponsive to topical management. 1

First-Line Topical Therapies

Non-Prescription Interventions

• Moisturizers/Emollients: Essential for all patients; should be applied liberally and frequently 1
• Bathing Practices: Use soap-free cleansers; conditional recommendation for bathing and wet wrap therapy 1
• Avoid Irritants: Minimize exposure to known triggers 1

Prescription Topical Therapies

• Topical Corticosteroids (TCS):

  • First-line anti-inflammatory treatment
  • Select potency based on severity, body location, and patient age
  • Apply to active lesions until clear
  • Proactive therapy: Continue 1-2× weekly to previously affected areas after clearing to prevent flares 1

• Topical Calcineurin Inhibitors (TCIs):

  • Tacrolimus ointment (0.03% for children 2-15 years; 0.1% for adults)
  • Pimecrolimus cream 1% (for patients ≥2 years) 2
  • Particularly useful for sensitive areas (face, neck, intertriginous areas)
  • Proactive therapy: Continue 2-3× weekly to prevent flares 1

• Topical PDE-4 Inhibitors: Strong recommendation for use 1

• Topical JAK Inhibitors: Strong recommendation for use 1

Not Recommended

• Topical antimicrobials/antiseptics: Not recommended for routine use 1
• Topical antihistamines: Not recommended 1

Prevention of Flares

• Implement proactive therapy with TCS (1-2× weekly) or TCIs (2-3× weekly) to previously affected areas after clearance 1
• Continue regular moisturizer use on all skin

Educational Interventions

• Educational programs ("eczema schools") strongly recommended as adjunctive therapy 1
• Video interventions recommended as supplement to conventional therapy 1
• Nurse-led programs and eczema workshops may be beneficial 1

Allergy Testing and Management

• Allergy testing: Only recommended when specific allergy concerns are identified in history (e.g., hives, urticaria) 1
• Patch testing: Consider for persistent/recalcitrant disease or suspected allergic contact dermatitis 1
• Food allergies:
  • Food elimination diets based solely on allergy test results not recommended 1
  • Consider food allergy evaluation in children <5 years with moderate-to-severe AD if:
    • Persistent despite optimized treatment, or
    • Clear history of immediate reaction after food ingestion 1

Systemic Therapies for Moderate-to-Severe Disease

For patients unresponsive to topical therapies:

Strong Recommendations For:

• Dupilumab: IL-4 receptor antagonist for moderate-to-severe AD 1, 3
• Tralokinumab: Strong recommendation 1
• JAK Inhibitors: Abrocitinib, baricitinib, upadacitinib 1

Conditional Recommendations For:

• Phototherapy: Consider for moderate-to-severe cases 1
• Immunomodulators: Azathioprine, cyclosporine, methotrexate, mycophenolate 1

Recommendation Against:

• Systemic corticosteroids: Not recommended for long-term use 1

Complementary Therapies

• Not recommended due to insufficient evidence:
  • Probiotics/prebiotics
  • Fish oils, evening primrose oil, borage oil
  • Multivitamin supplements, zinc, vitamins D, E, B12, and B6
  • Chinese herbal therapy, massage therapy
  • Aromatherapy, naturopathy, hypnotherapy, acupressure, autologous blood injections 1

Common Pitfalls to Avoid

1. Underuse of moisturizers: Should be applied multiple times daily, even when skin appears normal
2. Inappropriate TCS potency: Match potency to severity and location; avoid potent TCS on face/intertriginous areas
3. Premature discontinuation of treatment: Continue until complete clearance
4. Neglecting proactive therapy: Intermittent application of anti-inflammatories to previously affected areas prevents flares
5. Overreliance on antihistamines: Not effective for AD-related pruritus
6. Unnecessary dietary restrictions: Only eliminate foods with clear evidence of triggering flares
7. Overuse of antimicrobials: Only indicated for clinical infection, not colonization

Treatment Algorithm

1. All patients: Daily moisturizers + gentle cleansers
2. Mild-moderate flares: Add appropriate potency TCS or TCI
3. Sensitive areas: Use TCI or low-potency TCS
4. Inadequate response: Consider wet wraps, more potent TCS, or topical PDE-4/JAK inhibitors
5. Moderate-severe/refractory disease: Consider phototherapy or systemic therapy (dupilumab, JAK inhibitors, or immunomodulators)