What is the assessment and treatment plan for a patient with atopic dermatitis?

Assessment and Management of Atopic Dermatitis

The cornerstone of atopic dermatitis management is a combination of daily emollient use, topical anti-inflammatory therapy, trigger avoidance, and educational interventions, with systemic therapy reserved for severe or refractory cases. 1

Assessment

Disease Severity Evaluation

• Assess extent and intensity of skin lesions (erythema, edema/papulation, excoriations, lichenification)
• Evaluate distribution pattern (flexural surfaces in children, extensor surfaces in infants, hands/face in adults)
• Document pruritus severity and sleep disturbance
• Consider impact on quality of life and daily functioning

Trigger Identification

• Environmental irritants (acids, bleaches, fragrances, solvents, wool)
• Temperature and humidity extremes
• Emotional stress
• Potential allergens (only test if clinically indicated)

Treatment Algorithm

First-Line Therapy

1. Skin Care and Barrier Repair

   • Apply fragrance-free emollients immediately after bathing and 2-4 times daily 1, 2
   • Continue emollient use even when skin appears normal to prevent relapse 2
   • Use gentle, soap-free cleansers 2

2. Topical Anti-inflammatory Therapy

   • Topical Corticosteroids (TCS)

     • First-line treatment for flares 1
     • Match potency to severity and location:
       • Low potency (1% hydrocortisone): Face, intertriginous areas
       • Medium potency: Trunk, extremities
       • High potency: Lichenified areas, palms/soles
     • Apply twice daily during flares
     • Limit high-potency TCS to 2 consecutive weeks; amounts >50g/week should be avoided 3

   • Topical Calcineurin Inhibitors (TCI)

     • Tacrolimus 0.03% (children), 0.1% (adults)
     • Pimecrolimus 1%
     • Particularly useful for face, neck, intertriginous areas
     • May cause initial burning/stinging sensation 1

3. Flare Prevention (Proactive Therapy)

   • After disease stabilization, continue TCS 1-2× weekly or TCI 2-3× weekly to previously affected areas 1
   • This approach significantly reduces risk of flares and extends time to relapse 1

4. Educational Interventions

   • Educational programs and "eczema schools" improve outcomes 1
   • Video interventions and nurse-led programs are beneficial 1

Second-Line Therapy

1. Phototherapy

   • Consider when first-line treatments fail 1
   • Narrowband UVB is preferred modality 1
   • Typical regimen: 2-3 sessions/week initially 2
   • Can be used as maintenance therapy for chronic disease 1

2. Wet Wrap Therapy

   • For severe flares unresponsive to standard therapy
   • Maximum duration of 14 days 2
   • Apply TCS, then cover with wet bandages followed by dry layer

Third-Line Therapy (Severe/Refractory Cases)

1. Systemic Immunomodulators

   • Consider when disease is severe and refractory to topical therapy and phototherapy 1
   • Options include:
     • Dupilumab (FDA approved for patients ≥6 months) 2
     • Cyclosporine (3-6 mg/kg/day divided in two doses) 2
     • Methotrexate
     • Azathioprine
     • Mycophenolate mofetil

2. Systemic Corticosteroids

   • Generally not recommended due to risk of rebound flares upon discontinuation 2
   • Reserve only for most severe acute exacerbations as bridge therapy 2

Adjunctive Measures

Antihistamines

• Limited evidence for efficacy in reducing pruritus 1
• May be helpful for sleep disturbance due to sedating effects
• Not recommended as routine treatment 4

Antimicrobials

• Only use for clinically infected skin
• Consider bleach baths for recurrent infections 4

Environmental Modifications

• Temperature and humidity control
• Cotton clothing preferred over wool or synthetic fabrics 1
• Avoid activities causing excessive sweating 1

Special Considerations

Food Allergies

• Do not recommend food elimination diets based solely on allergy test results 1
• Consider food allergy evaluation in children <5 years with moderate-to-severe AD if:
  • Persistent AD despite optimal treatment, OR
  • History of immediate reaction after food ingestion 1, 5

Allergen Testing

• Only test for allergies when clinically indicated by history 1
• Patch testing should be considered for persistent/recalcitrant disease 1

Complementary Therapies

• Insufficient evidence to recommend Chinese herbal therapy, massage therapy, aromatherapy, or naturopathy 1
• No consistent evidence to support use of probiotics, prebiotics, fish oils, evening primrose oil, or vitamin supplements 1

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate therapy
• Consideration of systemic therapy
• Significant impact on quality of life despite treatment
• Need for allergen testing or dietary manipulation

Common Pitfalls to Avoid

• Overuse of high-potency topical corticosteroids on sensitive areas
• Discontinuing treatment too early after improvement
• Indiscriminate allergy testing without clinical correlation
• Unnecessary dietary restrictions
• Inadequate patient education about chronic nature of disease
• Failure to implement proactive maintenance therapy

By following this structured approach to assessment and management, most patients with atopic dermatitis can achieve good disease control and improved quality of life.