What is the recommended treatment for atopic dermatitis?

Treatment Recommendations for Atopic Dermatitis

For atopic dermatitis, a stepwise approach is recommended, beginning with topical therapies and progressing to systemic treatments for moderate-to-severe cases that don't respond adequately to topical management. 1

First-Line Therapy: Topical Treatments

Non-Pharmacological Approaches

• Moisturizers: Strong recommendation for regular use of moisturizers to maintain skin barrier function 1
• Bathing practices: Conditional recommendation for regular bathing with soap-free cleansers followed by immediate moisturizer application 1
• Wet wrap therapy: Conditional recommendation for use during acute flares 1

Topical Pharmacological Treatments

• Topical corticosteroids (TCS): Strong recommendation as first-line anti-inflammatory treatment 1

  • Select potency based on severity and location:
  • Low potency for face, intertriginous areas, and thin skin
  • Medium to high potency for trunk and extremities
  • Apply once or twice daily during flares
  • For maintenance: Use 1-2× per week to previously affected areas to prevent flares 1

• Topical calcineurin inhibitors (TCIs): Strong recommendation 1

  • Tacrolimus 0.03% or 0.1% ointment
  • Pimecrolimus 1% cream
  • Particularly useful for sensitive areas (face, neck, intertriginous areas)
  • For maintenance: Use 2-3× per week to previously affected areas to prevent flares 1

• Topical PDE-4 inhibitors: Strong recommendation 1

  • Crisaborole ointment for mild to moderate AD

• Topical JAK inhibitors: Strong recommendation 1

  • Ruxolitinib cream for short-term and non-continuous chronic treatment

Not Recommended Topical Treatments

• Topical antimicrobials/antiseptics: Conditional recommendation against routine use unless there is clinical evidence of infection 1
• Topical antihistamines: Conditional recommendation against use 1

Second-Line Therapy: Phototherapy

• Conditional recommendation for narrowband UVB phototherapy when AD is not adequately controlled with topical treatments 1
• Requires multiple weekly sessions in a specialized facility

Third-Line Therapy: Systemic Treatments

For moderate-to-severe AD not adequately controlled with topical therapies or phototherapy:

Biologics and JAK Inhibitors

• Strong recommendation for the following agents 1:
  • Dupilumab: FDA-approved for patients ≥6 months with moderate-to-severe AD not adequately controlled with topical prescription therapies 2
  • Tralokinumab
  • JAK inhibitors: Abrocitinib, baricitinib, and upadacitinib

Other Systemic Immunomodulators

• Conditional recommendation for the following agents 1:
  • Cyclosporine: 3-5 mg/kg/day, most rapid acting systemic agent
  • Methotrexate: 7.5-25 mg weekly
  • Azathioprine: 1-3 mg/kg/day
  • Mycophenolate mofetil: 1-2 g/day

Not Recommended Systemic Treatments

• Conditional recommendation against systemic corticosteroids due to risk of rebound flares and adverse effects 1
• Systemic antibiotics: Not recommended unless there is clinical evidence of infection 1
• Systemic antihistamines: Insufficient evidence to recommend routine use 1
  • Short-term use of sedating antihistamines may be considered for sleep disturbance due to itch

Patient Education and Adjunctive Approaches

• Educational programs are recommended as an adjunct to conventional therapy 1
• Food elimination diets are not recommended unless there is a confirmed IgE-mediated food allergy 1
• Children <5 years with moderate-to-severe AD should be considered for food allergy evaluation if they have persistent AD despite optimized treatment or history of immediate reaction after food ingestion 1

Important Caveats

1. Adherence challenges: Poor adherence to topical therapy is common and may lead to treatment failure
2. Corticosteroid phobia: Address patient concerns about TCS side effects, as most topical corticosteroids can achieve greater effective drug levels in superficial skin layers than oral prednisone 3
3. Infection management: Secondary bacterial infections require appropriate antimicrobial treatment
4. Long-term safety: JAK inhibitors require monitoring for potential adverse effects
5. Treatment escalation: Don't delay stepping up therapy when lower-tier treatments fail to provide adequate control

This evidence-based approach prioritizes treatments with the strongest evidence for improving disease control and quality of life while minimizing potential adverse effects.