What medications are used to treat atopic dermatitis?

Medications for Atopic Dermatitis

For most patients with atopic dermatitis, a stepwise approach beginning with topical therapies (moisturizers, topical corticosteroids, calcineurin inhibitors, PDE-4 inhibitors, and JAK inhibitors) is recommended as first-line treatment, with phototherapy and systemic therapies reserved for more severe or refractory cases. 1

First-Line Topical Therapies

Non-Prescription Options

• Moisturizers/Emollients
  • Apply 3-8 times daily, even when skin appears normal 2
  • Apply immediately after bathing to lock in moisture
  • Ointments provide maximum occlusion (best for very dry skin)
  • Creams offer good balance of hydration and acceptability

Prescription Topical Medications

1. Topical Corticosteroids (TCS)

   • First-line anti-inflammatory treatment for flares 1
   • Apply twice daily for up to 4 weeks initially
   • Potency selection based on location and severity:
     • Low potency (Class 6-7): Face, intertriginous areas
     • Medium potency (Class 3-5): Trunk, extremities
     • High potency (Class 1-2): Thick, lichenified lesions
   • Monitor for adverse effects: skin atrophy, striae, telangiectasia
   • Consider proactive therapy (twice weekly application) for maintenance

2. Topical Calcineurin Inhibitors (TCIs)

   • Strong recommendation by guidelines 1
   • Examples: tacrolimus, pimecrolimus
   • Pimecrolimus indicated as second-line therapy for mild to moderate AD in patients ≥2 years 3
   • Particularly useful for sensitive areas (face, neck, intertriginous areas)
   • No risk of skin atrophy, making them suitable for long-term use

3. Topical PDE-4 Inhibitors

   • Strong recommendation by guidelines 1
   • Example: crisaborole
   • For mild to moderate AD

4. Topical JAK Inhibitors

   • Strong recommendation by guidelines 1
   • For mild to moderate AD

Second-Line and Advanced Therapies

Phototherapy

• Conditional recommendation for use in moderate to severe AD 1
• Options include narrowband UVB, UVA1, and PUVA
• Particularly useful when topical therapies are insufficient

Systemic Therapies

For severe, widespread, or refractory AD:

1. Biologics (Strong recommendations) 1

   • Dupilumab
   • Tralokinumab

2. Oral JAK Inhibitors (Strong recommendations) 1

   • Abrocitinib
   • Baricitinib
   • Upadacitinib

3. Immunomodulators (Conditional recommendations) 1

   • Cyclosporine
   • Methotrexate
   • Azathioprine
   • Mycophenolate

4. Systemic Corticosteroids

   • Conditional recommendation AGAINST use 1
   • Associated with rebound flares upon discontinuation
   • Significant adverse effects with long-term use
   • May increase infection risk in patients with S. aureus colonization

Treatment Algorithm

1. Initial Assessment

   • Determine severity and extent of disease
   • Identify and eliminate trigger factors
   • Evaluate impact on quality of life

2. Basic Management (All Patients)

   • Daily skin care with gentle cleansers
   • Liberal use of moisturizers
   • Avoidance of known triggers

3. Mild to Moderate AD

   • Topical corticosteroids for active lesions
   • Consider TCIs for sensitive areas or long-term use
   • Add topical PDE-4 or JAK inhibitors if response inadequate

4. Moderate to Severe AD

   • Optimize topical therapy
   • Consider phototherapy if topicals insufficient
   • If inadequate response, consider systemic therapy

5. Severe or Refractory AD

   • Biologics (dupilumab, tralokinumab)
   • JAK inhibitors (abrocitinib, baricitinib, upadacitinib)
   • Traditional immunomodulators if biologics/JAK inhibitors unavailable or contraindicated

Special Considerations

• Infection Management

  • Treat clinically evident infections with appropriate antibiotics
  • Consider antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 2
  • Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections

• Proactive Therapy Approach

  • Long-term, low-dose intermittent application of anti-inflammatory therapy to previously affected skin 4
  • Helps prevent flares and stabilize skin barrier
  • Particularly effective with TCS or TCIs applied 2-3 times weekly to previously affected areas

• Common Pitfalls to Avoid

  • Using potent TCS on face/intertriginous areas
  • Inadequate amounts of topical medications
  • Abrupt discontinuation of treatment leading to rebound flares
  • Relying on oral antihistamines for itch control (limited evidence)
  • Using systemic corticosteroids (risk of rebound flares)
  • Neglecting moisturizer use between flares

The treatment of atopic dermatitis requires a comprehensive approach with appropriate selection of medications based on disease severity, affected areas, and patient factors. Regular follow-up and adjustment of therapy are essential for optimal disease control and improved quality of life.