What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

The most effective treatment approach for atopic dermatitis involves a stepwise algorithm starting with topical corticosteroids as first-line therapy, with maintenance therapy using intermittent application (1-2× weekly) to prevent flares after disease stabilization. 1

First-Line Treatments

Topical Therapies

• Topical corticosteroids:

  • Select potency based on location:
    • High-potency (e.g., clobetasol 0.05%): For non-facial, non-intertriginous areas in severe cases
    • Medium-potency: For body areas
    • Low-potency: For face, neck, and intertriginous areas 2
  • Apply once daily (as effective as twice daily for potent corticosteroids) 2
  • Limit high-potency use to 2-4 weeks to avoid skin atrophy 2

• Topical calcineurin inhibitors (TCIs):

  • First-line for facial atopic dermatitis 2
  • Pimecrolimus 1% cream: Effective for mild to moderate atopic dermatitis 3
    • In clinical trials, 35% of patients treated with pimecrolimus were clear or almost clear of signs compared to 18% with vehicle 3
  • Tacrolimus: Alternative TCI option 4

Essential Adjunctive Therapies

• Emollients/Moisturizers:

  • Apply 3-8 times daily, even when skin appears normal 2
  • Ointments provide maximum occlusion (best for very dry skin)
  • Apply immediately after bathing to lock in moisture 2

• Bathing practices:

  • Use gentle, pH-neutral synthetic detergents instead of soap 2
  • Consider bleach baths (0.005% sodium hypochlorite twice weekly) to reduce bacterial colonization 2

Second-Line and Advanced Treatments

Phototherapy

• Consider for moderate to severe cases not responding to topical treatments 1, 5
• Narrowband UVB is generally preferred 2

Systemic Therapies

For severe, refractory cases:

• Strong recommendations (per 2024 guidelines) 1:

  • Dupilumab
  • Tralokinumab
  • Abrocitinib
  • Baricitinib
  • Upadacitinib

• Conditional recommendations 1:

  • Cyclosporine
  • Methotrexate
  • Azathioprine
  • Mycophenolate

• Not recommended 1:

  • Systemic corticosteroids (due to risk of rebound flares and adverse events)

Flare Prevention and Management

Proactive Therapy

• After disease stabilization, continue topical corticosteroids (1-2× weekly) or calcineurin inhibitors (2-3× weekly) on previously affected skin to prevent flares 1

Infection Management

• Treat clinically evident infections with appropriate antibiotics 1
• Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 2

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 Considerations

• Assess for environmental and food allergies during history taking 1
• Allergy testing should be guided by history, not performed independently 1
• Patch testing should be considered in patients with persistent/recalcitrant disease 1
• Food elimination diets based solely on allergy test results are not recommended 1

Common Pitfalls to Avoid

1. Overuse of topical steroids: Can lead to skin atrophy and telangiectasia, especially on the face 6
2. Underuse of emollients: These are fundamental to management and should be used liberally
3. Inappropriate use of systemic corticosteroids: Despite quick relief, these are not recommended due to rebound flares 1
4. Neglecting maintenance therapy: Intermittent application of topical treatments prevents flares 1
5. Relying on antihistamines for itch control: Oral antihistamines are not recommended as they do not effectively reduce pruritus 4

By following this evidence-based approach, most patients with atopic dermatitis can achieve good disease control and improved quality of life.