What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

For moderate to severe atopic dermatitis, strong recommendations include dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, while phototherapy, cyclosporine, methotrexate, azathioprine, and mycophenolate are conditionally recommended. 1

First-line Treatments

Topical Therapies

• Topical corticosteroids: First-line treatment for AD flare-ups 2

  • Selection based on affected site:
    • Face/sensitive areas: Low-potency (e.g., hydrocortisone 0.1-2.5%)
    • Body: Medium to high-potency for short courses
  • Apply twice daily during flares
  • Caution: Can cause skin atrophy with prolonged use 3

• Topical calcineurin inhibitors (TCIs): First-line treatment in conjunction with topical corticosteroids 2

  • Pimecrolimus 1% cream: FDA-approved for mild to moderate AD in patients ≥2 years 4
  • Tacrolimus: Particularly useful for sensitive areas like face
  • Advantage: No risk of skin atrophy compared to corticosteroids 3

Non-pharmacological Approaches

• Moisturizers/emollients: Apply liberally at least twice daily, especially after bathing
• Soap-free cleansers: Use gentle, pH-neutral products
• Daily bathing: With soap-free cleansers to remove allergens and irritants

Second-line Treatments

Phototherapy

• Conditionally recommended for moderate to severe AD unresponsive to first-line treatments 1
• Various modalities available (UVB, narrowband UVB)
• Should be administered under specialist supervision

Systemic Therapies for Moderate-to-Severe Disease

1. Biologics and JAK inhibitors (strong recommendations) 1:

   • Dupilumab
   • Tralokinumab
   • JAK inhibitors: Abrocitinib, baricitinib, upadacitinib

2. Traditional immunosuppressants (conditional recommendations) 1:

   • Cyclosporine
   • Methotrexate
   • Azathioprine
   • Mycophenolate mofetil

Treatment Algorithm

1. Mild AD:

   • Daily emollients and gentle skin care
   • Low-potency topical corticosteroids for flares
   • TCIs for sensitive areas or maintenance

2. Moderate AD:

   • Medium-potency topical corticosteroids for flares
   • TCIs for sensitive areas and maintenance
   • Consider phototherapy if inadequate response

3. Severe AD:

   • High-potency topical corticosteroids for short courses
   • Consider systemic therapy if:

     • 10% body surface area affected

     • Significant impact on quality of life
     • Failure of topical treatments
   • First options: Dupilumab, tralokinumab, or JAK inhibitors
   • Alternative options: Cyclosporine, methotrexate, azathioprine, mycophenolate

Important Considerations

• Systemic corticosteroids: Conditionally recommended against due to rebound flares and adverse effects 1

• Infection management:

  • Treat clinically evident bacterial infections with appropriate antibiotics
  • Monitor for signs of viral infections (eczema herpeticum)

• Antihistamines: Not recommended for pruritus control in AD 2

• Monitoring:

  • Assess response after 2-4 weeks of treatment
  • For systemic therapies, follow appropriate laboratory monitoring based on medication

Common Pitfalls

• Overusing topical corticosteroids, especially on sensitive areas
• Underusing moisturizers and proper skin care
• Failing to address secondary infections
• Using systemic corticosteroids for long-term management
• Not considering phototherapy before moving to systemic agents
• Inadequate patient education about chronic nature of disease

By following this evidence-based approach, most patients with atopic dermatitis can achieve significant improvement in symptoms and quality of life.