What are the treatment options for dermatitis?

Treatment Options for Dermatitis

The primary treatment for dermatitis includes topical corticosteroids as first-line therapy for acute flares, with topical calcineurin inhibitors recommended for sensitive areas, and regular use of moisturizers as essential maintenance therapy. 1

First-Line Treatments

Topical Corticosteroids (TCS)

• Strong recommendation for use in treating active dermatitis 1
• Selection based on location and severity:
  • Mild-moderate potency for face, neck, intertriginous areas
  • Moderate-high potency for trunk and extremities
  • Very high potency for thick, lichenified areas
• Apply twice daily during active flares
• Maintenance therapy: Apply 1-2× per week to previously affected areas to prevent flares 1
• Potential side effects: skin atrophy and telangiectasia with prolonged use, especially with higher potency formulations 2

Topical Calcineurin Inhibitors (TCIs)

• Strong recommendation for use 1
• Preferred for sensitive areas (face, neck, intertriginous areas) 3
• Options:
  • Tacrolimus 0.03% or 0.1% ointment
  • Pimecrolimus 1% cream
• Maintenance therapy: Apply 2-3× per week to prevent flares 1
• Advantages: No risk of skin atrophy, making them safer for long-term use 2
• Studies show tacrolimus has superior efficacy compared to weak corticosteroids 4

Essential Adjunctive Therapies

Moisturizers/Emollients

• Strong recommendation for regular use 1
• Apply immediately after bathing and throughout the day 5
• Choose products free of allergenic surfactants, preservatives, fragrances, or dyes 5
• Helps repair skin barrier function and reduces need for prescription medications

Bathing Practices

• Conditional recommendation for appropriate bathing 1
• Use lukewarm water and soap-free cleansers 6
• Immediately apply moisturizer after bathing to lock in moisture

Second-Line and Adjunctive Treatments

Wet Wrap Therapy

• Conditional recommendation for use in severe or resistant cases 1
• Apply medication, cover with damp gauze, then dry layer
• Particularly helpful for acute, severe flares

Educational Interventions

• Recommended as an adjunct to conventional therapy 1
• Options include:
  • Training programs/"eczema schools"
  • Video interventions
  • Nurse-led programs

Newer Topical Agents

• Topical PDE-4 inhibitors (e.g., crisaborole): Strong recommendation 1
• Topical JAK inhibitors: Strong recommendation 1
• May be considered when traditional options fail or are contraindicated

Treatments Not Recommended

Topical Antimicrobials/Antiseptics

• Conditional recommendation against routine use 1
• Only indicated when clear signs of secondary infection are present

Topical Antihistamines

• Conditional recommendation against use 1
• Limited efficacy for pruritus and potential for contact sensitization

Food Elimination Diets

• Not recommended based solely on food allergy test results 1
• Only indicated for patients with true IgE-mediated allergies

Treatment Algorithm

1. For mild dermatitis:

   • Regular moisturizers
   • Low-potency TCS for flares
   • Consider TCIs for face/sensitive areas

2. For moderate dermatitis:

   • Regular moisturizers
   • Medium-potency TCS for body
   • TCIs for face/sensitive areas
   • Consider maintenance therapy to prevent flares

3. For severe dermatitis:

   • Regular moisturizers
   • High-potency TCS for short courses (1-2 weeks)
   • TCIs for face/sensitive areas
   • Consider wet wrap therapy
   • Consider referral for phototherapy or systemic agents if inadequate response 1

Common Pitfalls to Avoid

• Underuse of moisturizers: They are essential, not optional
• Overuse of high-potency TCS: Can lead to skin atrophy, especially on face and intertriginous areas
• Inadequate duration of treatment: Continue treatment until complete clearance
• Neglecting maintenance therapy: Regular use of moisturizers and intermittent TCS/TCIs prevents flares
• Misdiagnosis: Consider patch testing for persistent/recalcitrant cases to rule out allergic contact dermatitis 5
• Reliance on barrier creams alone: They provide insufficient protection against irritants 5

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