What are the recommended treatments for managing dermatitis?

Management of Dermatitis

The management of dermatitis should follow a stepwise approach with moisturizers, topical corticosteroids, topical calcineurin inhibitors, and topical PDE-4 and JAK inhibitors as first-line treatments, with systemic therapies reserved for severe cases unresponsive to topical therapy. 1

First-Line Treatments

Moisturizers and Skin Care

• Apply moisturizers at least twice daily as the foundation of dermatitis management 1, 2
• Use alcohol-free moisturizers, preferably with urea-containing (5-10%) formulations 2
• Use emollients as soap substitutes for cleansing to avoid further irritation 2
• Avoid excessive heat, humidity, and change clothes when damp from sweat 2
• Use gentle, pH-neutral synthetic detergents and non-soap cleansers 2

Topical Anti-inflammatory Treatments

1. Topical Corticosteroids (TCS)

   • Strong recommendation for use in atopic dermatitis 1
   • Apply medium-potency TCS (e.g., triamcinolone acetonide 0.1%) as a thin film to affected areas 1-2 times daily for 1-4 weeks 2
   • Use lower potency TCS (e.g., hydrocortisone 2.5%) for face, genitals, and intertriginous areas 2
   • Limit to short-term use to minimize side effects such as skin atrophy 3

2. Topical Calcineurin Inhibitors (TCIs)

   • Strong recommendation for use 1
   • Options include tacrolimus ointment 0.1% or pimecrolimus cream 1% 2, 4
   • Particularly useful for sensitive areas (face, neck, intertriginous areas) 4
   • FDA-approved as second-line therapy for short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis 4
   • Can be used for maintenance therapy to prevent flares 2

3. Topical PDE-4 Inhibitors

   • Strong recommendation for use 1
   • Effective for mild to moderate atopic dermatitis 1

4. Topical JAK Inhibitors

   • Strong recommendation for use 1
   • Newer option for treatment of atopic dermatitis 1

Second-Line Treatments

Phototherapy

• Conditional recommendation for use in moderate to severe cases unresponsive to topical treatments 1, 5
• Options include narrowband UVB (NB-UVB) for chronic cases and UVA1 for acute cases 5
• Generally considered safe and well-tolerated, but has limitations related to costs, availability, and patient compliance 5
• Should be performed under specialist supervision, especially in children 5

Wet Wrap Therapy

• Conditional recommendation for use 1
• Helpful for acute, severe flares 1

Third-Line Treatments (Severe Cases)

Systemic Therapies

• Reserved for severe, widespread dermatitis unresponsive to topical treatments 1
• Strong recommendations for:
  • Biologics: dupilumab, tralokinumab 1
  • Oral JAK inhibitors: abrocitinib, baricitinib, upadacitinib 1
• Conditional recommendations for:
  • Immunosuppressants: azathioprine, cyclosporine, methotrexate, mycophenolate 1
• Conditional recommendation against systemic corticosteroids 1

Treatments NOT Recommended

1. Topical Antimicrobials/Antiseptics

   • Conditional recommendation against routine use 1
   • Only use systemic antibiotics for confirmed infections 2

2. Topical Antihistamines

   • Conditional recommendation against use 1
   • Oral antihistamines are not recommended for routine treatment but may help with sleep disruption due to itching 2, 6

Special Considerations

Contact Dermatitis

• Identify and avoid triggering substances 7
• For allergic contact dermatitis, mid- or high-potency topical steroids are effective for localized lesions 7
• For extensive involvement (>20% body surface area), systemic steroids may be required 7

Monitoring and Follow-up

• Reassess after 2 weeks of treatment to monitor progress 2
• Watch for signs of skin atrophy, secondary bacterial infection, and treatment failure 2
• Consider dermatology referral if:
  • No improvement after 4-9 weeks of appropriate therapy
  • Diagnosis is uncertain
  • Lesions are widespread or rapidly progressing
  • Secondary complications develop 2

Patient Education

• Educate patients about the chronic, relapsing nature of dermatitis 2
• Emphasize the importance of consistent moisturization and trigger avoidance 2
• Explain proper application techniques for medications 2
• Reassure patients that the condition is not infectious or related to poor hygiene 2

By following this structured approach to dermatitis management, clinicians can effectively control symptoms, prevent flares, and improve patients' quality of life while minimizing potential treatment-related adverse effects.