What is the recommended treatment for atopic dermatitis?

Treatment Recommendations for Atopic Dermatitis

The recommended treatment for atopic dermatitis follows a stepwise approach, with topical therapies as first-line treatment, followed by phototherapy and systemic agents for refractory cases.

First-Line Therapy: Topical Treatments

Non-Pharmacologic Interventions

• Moisturizers/emollients are strongly recommended as foundational therapy for all patients with atopic dermatitis 1
• Apply moisturizers immediately after bathing to improve skin barrier function
• Use fragrance-free formulations to minimize irritation

Topical Anti-inflammatory Agents

• Topical corticosteroids (TCS) are the primary pharmacologic treatment for atopic dermatitis flares 1

  • Select potency based on severity, body location, and patient age
  • For sensitive areas (face, neck, intertriginous areas): use low-potency formulations
  • For thicker skin (extremities, trunk): medium to high-potency may be appropriate
  • Ointment formulations provide better penetration than creams or lotions

• Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus are recommended:

  • As alternatives to TCS for sensitive areas 1
  • For maintenance therapy to prevent flares
  • Pimecrolimus 1% cream is indicated as second-line therapy for mild to moderate atopic dermatitis in patients ≥2 years old who have failed other topical prescription treatments 2

Maintenance Therapy to Prevent Flares

• Proactive maintenance therapy is strongly recommended after disease stabilization:
  • TCS: Apply 1-2 times weekly to previously affected areas 1
  • TCIs: Apply 2-3 times weekly to previously affected areas 1

Second-Line Therapy: Phototherapy

• Phototherapy is recommended for patients who fail to respond adequately to optimized topical regimens 1
• Narrowband UVB is the preferred modality 1
• Typically requires 2-3 sessions per week initially

Third-Line Therapy: Systemic Agents

For patients with inadequate response to topical therapies and phototherapy:

Biologics and JAK Inhibitors

• Strong recommendations are made for the following agents 1:
  • Dupilumab (IL-4 receptor antagonist)
  • Tralokinumab
  • JAK inhibitors: abrocitinib, baricitinib, and upadacitinib

Other Immunomodulatory Agents

• Conditional recommendations for 1:

  • Azathioprine
  • Cyclosporine
  • Methotrexate
  • Mycophenolate

• Conditional recommendation against systemic corticosteroids due to risk of rebound flares upon discontinuation 1

Adjunctive Therapies

Educational Interventions

• Educational programs ("eczema schools") are recommended as adjuncts to conventional therapy 1
• Video interventions and nurse-led programs may be useful 1

Allergy Testing and Dietary Interventions

• Allergy testing is not recommended without specific history suggesting allergies 1
• Food elimination diets based solely on allergy test results are not recommended 1
• Children <5 years with moderate-severe AD should be considered for food allergy evaluation only if:
  • AD persists despite optimized treatment, or
  • There is a reliable history of immediate reaction after food ingestion 1

Antimicrobials and Antihistamines

• Topical antimicrobials are not routinely recommended 1
• Antihistamines are not effective for pruritus in atopic dermatitis 3

Special Considerations

Skin Atrophy Risk

• Prolonged use of topical corticosteroids, especially higher potency formulations, can lead to skin atrophy 4
• TCIs (tacrolimus, pimecrolimus) do not cause skin atrophy and may be preferable for long-term use, especially on sensitive areas 4

Pediatric Patients

• Hydrocortisone butyrate 0.1% has been shown to be safe without adrenal suppression in children 5-12 years 5
• Tacrolimus 0.03% has demonstrated superior efficacy compared to hydrocortisone for pediatric atopic dermatitis 6

Treatment Algorithm

1. Start with basic therapy:

   • Daily moisturizers
   • Gentle cleansers
   • Trigger avoidance

2. For active flares:

   • Add appropriate potency TCS twice daily
   • Consider TCIs for sensitive areas

3. After improvement:

   • Transition to maintenance therapy with intermittent TCS (1-2×/week) or TCIs (2-3×/week)

4. For inadequate response:

   • Consider phototherapy (narrowband UVB)

5. For refractory disease:

   • Consider systemic therapy with dupilumab or other approved biologics/JAK inhibitors
   • Consider traditional immunosuppressants (cyclosporine, methotrexate, azathioprine) if biologics unavailable