What is the recommended treatment for atopic dermatitis?

Treatment Recommendations for Atopic Dermatitis

The recommended first-line treatment for atopic dermatitis is daily moisturization combined with topical corticosteroids for flares, with topical calcineurin inhibitors as alternative or adjunctive therapy for maintenance and sensitive areas. 1, 2

Step-by-Step Treatment Algorithm

First-Line Treatment

1. Daily Skin Care

   • Apply moisturizers at least twice daily, preferably immediately after bathing to lock in moisture 1
   • Use gentle, non-soap cleansers for bathing 1
   • Avoid identified triggers (heat, humidity, irritants) 1

2. Acute Flare Management

   • Topical Corticosteroids (TCS) - Apply to affected areas:
     • For face/neck/intertriginous areas: Low-potency (hydrocortisone 2.5%)
     • For body: Medium-potency (triamcinolone 0.1%) for 1-4 weeks 1
     • Apply as a thin film 1-2 times daily until flare resolves 1

3. Maintenance Therapy

   • Continue daily moisturization even when skin appears clear 1
   • Apply TCS 1-2 times weekly to previously affected areas to prevent flares 2
   • OR use topical calcineurin inhibitors (TCIs) 2-3 times weekly for maintenance 2, 1

Second-Line Treatments

1. Topical Calcineurin Inhibitors

   • Pimecrolimus 1% or tacrolimus 0.1% cream twice daily 1, 3
   • Particularly useful for face, neck, and skin folds where TCS may cause atrophy 1, 4
   • FDA approved as second-line therapy for short-term and non-continuous chronic treatment 3

2. Wet Wrap Therapy

   • For moderate-to-severe cases: Apply topical medication, then cover with wet dressings 1
   • Particularly helpful for intense flares not responding to standard therapy

Third-Line Treatments

1. Phototherapy

   • Consider for moderate-to-severe AD unresponsive to topical treatments 1
   • Options include narrowband UVB, broadband UVB, or PUVA 1

2. Systemic Therapy (for severe, widespread disease)

   • Biologics: Dupilumab (preferred first-line systemic agent) or tralokinumab 2, 1
   • JAK Inhibitors: Abrocitinib, baricitinib, upadacitinib 2
   • Traditional immunosuppressants: Cyclosporine, methotrexate, azathioprine, mycophenolate 2

Special Considerations

Infection Management

• Obtain bacterial cultures if infection is suspected (crusting, weeping lesions) 1
• Use appropriate systemic antibiotics for confirmed infections 1
• Topical antibiotics are not recommended for non-infected AD 2

Antihistamine Use

• Not recommended as routine treatment for AD in the absence of urticaria 2
• Short-term use of sedating antihistamines may help with sleep disruption due to itching 2

Treatment Efficacy and Safety Notes

• Topical Calcineurin Inhibitors vs. Corticosteroids:

  • TCIs do not cause skin atrophy, making them safer for long-term use and sensitive areas 4
  • Studies show tacrolimus 0.03% is more effective than hydrocortisone for pediatric AD 5

• Corticosteroid Safety:

  • Low to medium-potency corticosteroids have minimal risk of adrenal suppression with proper use 6
  • Avoid undertreatment due to "steroid phobia" as this can lead to inadequate symptom control 1

• Newer Treatments:

  • Dupilumab, tralokinumab, and JAK inhibitors show strong efficacy for moderate-to-severe AD 2
  • The American Academy of Dermatology makes strong recommendations for these newer agents 2

Common Pitfalls to Avoid

• Discontinuing moisturizers when skin appears clear (leads to relapse) 1
• Relying solely on antihistamines for itch control 1
• Using topical antibiotics for non-infected AD 2
• Prolonged use of topical corticosteroids on sensitive areas (face, neck, folds) 1
• Using systemic corticosteroids (should be avoided if possible) 2

When to Refer to a Dermatologist

• No improvement after 4 weeks of appropriate therapy
• Uncertain diagnosis
• Development of secondary complications
• Severe, widespread disease requiring systemic therapy 1

Regular reassessment after 2 weeks of treatment is recommended to monitor progress and adjust therapy as needed 1.