What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

For most patients with atopic dermatitis, a stepwise approach starting with emollients and topical therapies, progressing to phototherapy, and then to systemic therapies for severe cases is strongly recommended based on the latest guidelines. 1

First-Line Treatments

Non-Pharmacologic Interventions

• Emollients/Moisturizers
  • Apply liberally and frequently, especially after bathing to lock in moisture 2
  • Serve as front-line therapy for both acute and maintenance treatment 1
  • Should be applied immediately after bathing for maximum benefit

Topical Anti-inflammatory Therapies

• Topical Corticosteroids (TCS)

  • First-line pharmacologic therapy when non-pharmacologic interventions are insufficient 1, 2
  • Select potency based on severity and location:
    • Low potency for face, neck, intertriginous areas
    • Medium to high potency for trunk and extremities
  • Use caution in thin-skinned areas to avoid atrophy
  • Consider proactive maintenance therapy with twice-weekly application to prevent relapse 2

• Topical Calcineurin Inhibitors (TCIs) (tacrolimus, pimecrolimus)

  • Effective steroid-sparing agents for acute and maintenance therapy 1
  • Particularly useful for sensitive areas (face, neck, genitals) 2
  • May cause burning sensation initially; preceding with TCS can lessen this effect 1
  • No risk of skin atrophy, making them suitable for long-term use

Second-Line Treatments

Phototherapy

• Recommended when topical therapies fail to adequately control symptoms 1
• Options include:
  • Narrow-band UVB (most commonly recommended) 1
  • Broad-band UVB
  • UVA1
  • UVAB
• Treatment protocols should be structured and reviewed by providers knowledgeable in phototherapy techniques 1
• Natural sunlight is likely less effective than artificial light sources 1

Third-Line Treatments (For Moderate-to-Severe Disease)

Biologics (Strong Recommendations)

• Dupilumab - First FDA-approved biologic for AD 1
• Tralokinumab - IL-13 inhibitor with strong evidence of efficacy 1

JAK Inhibitors (Strong Recommendations)

• Abrocitinib 1
• Baricitinib 1
• Upadacitinib 1

Traditional Immunomodulators (Conditional Recommendations)

• Cyclosporine - Rapid onset of action, suitable for short-term control 1
• Methotrexate - Slower onset but may be better tolerated long-term 1
• Azathioprine - Effective but requires monitoring for adverse effects 1
• Mycophenolate mofetil - Alternative when other options aren't suitable 1

Treatments to Avoid or Use with Caution

Systemic Corticosteroids

• Not recommended for routine use in atopic dermatitis 1, 2
• May cause rebound flares after discontinuation 1
• Consider only in limited circumstances:
  • Acute severe exacerbations requiring immediate control
  • As a bridge therapy while transitioning to other systemic treatments
  • Short courses only to minimize adverse effects 2

Other Treatments with Insufficient Evidence

• Systemic antibiotics (only for clinically evident infection) 1
• Oral antihistamines (not effective for pruritus; may help with sleep disturbance) 1
• Montelukast, apremilast, ustekinumab, IVIG, interferon gamma 1

Adjunctive Treatments

For Secondary Infections

• Bleach baths (0.005% sodium hypochlorite) twice weekly for infection-prone patients 1
• Systemic antibiotics only when clear evidence of infection exists 1

For Severe Itch

• Short-term antihistamines may help with sleep disturbance but are not effective for daytime pruritus 1

Treatment Algorithm

1. Mild AD:

   • Daily emollients
   • Low to medium potency TCS for active lesions
   • TCIs for sensitive areas

2. Moderate AD:

   • All treatments for mild AD
   • Medium to high potency TCS for active lesions
   • Consider phototherapy if inadequate response

3. Severe AD:

   • All treatments for moderate AD
   • Consider phototherapy
   • If inadequate response, progress to systemic therapy:
     • First options: Dupilumab, tralokinumab, or JAK inhibitors
     • Alternative options: Cyclosporine, methotrexate, azathioprine, or mycophenolate mofetil

Common Pitfalls to Avoid

• Undertreatment due to "steroid phobia" 1
• Prolonged use of high-potency TCS on sensitive areas
• Using systemic corticosteroids as regular treatment 1, 2
• Relying on antihistamines for daytime pruritus control 1
• Neglecting the importance of regular emollient use
• Using systemic antibiotics without evidence of infection 1

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