What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

The most effective approach to treating atopic dermatitis follows a stepwise progression from topical therapies to phototherapy and systemic agents for refractory cases, with strong recommendations for dupilumab, tralokinumab, and JAK inhibitors (abrocitinib, baricitinib, and upadacitinib) in moderate-to-severe disease. 1, 2

First-Line Therapies

Basic Skin Care

• Moisturizers/emollients are foundational therapy for all patients
  • Apply immediately after bathing to improve skin barrier function
  • Use regularly even when skin appears normal

Topical Anti-inflammatory Treatments

• Topical corticosteroids (TCS)

  • Primary pharmacologic treatment for flares
  • Select potency based on severity, body location, and patient age
  • Caution: Can cause skin atrophy with prolonged use, especially on sensitive areas like the face 3

• Topical calcineurin inhibitors (TCIs)

  • Pimecrolimus 1% cream and tacrolimus ointment
  • Particularly useful for sensitive areas (face, neck, intertriginous areas)
  • FDA-approved for patients 2 years and older 4
  • Less risk of skin atrophy compared to topical corticosteroids 3

Maintenance Therapy

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

Second-Line Therapy

Phototherapy

• Recommended for patients who fail to respond adequately to optimized topical regimens
• Narrowband UVB is the preferred modality
• Typically requires 2-3 sessions per week initially
• Limitations include accessibility, cost, and time commitment 1, 2
• Potential adverse effects include sunburn-like reactions and theoretical risk of skin cancer 1

Third-Line Therapies (Systemic)

Strongly Recommended Systemic Therapies 1

• Biologics:

  • Dupilumab: First biologic approved for moderate-to-severe AD
  • Tralokinumab: IL-13 inhibitor

• JAK Inhibitors:

  • Abrocitinib
  • Baricitinib
  • Upadacitinib

Conditionally Recommended Systemic Therapies 1, 2

• Azathioprine
• Cyclosporine
• Methotrexate
• Mycophenolate

Not Recommended

• Systemic corticosteroids are conditionally recommended against due to risk of rebound flares upon discontinuation 1, 2, 5
  • Significant side effects include growth suppression in children, osteoporosis, adrenal insufficiency, hypertension, glucose intolerance, and opportunistic infections 5

Treatment Algorithm

1. Mild AD:

   • Daily emollients/moisturizers
   • Low-potency TCS for flares
   • TCIs for sensitive areas

2. Moderate AD:

   • Daily emollients/moisturizers
   • Medium-potency TCS for body
   • TCIs for face and intertriginous areas
   • Consider proactive maintenance therapy

3. Moderate-to-Severe AD unresponsive to topicals:

   • Consider phototherapy (narrowband UVB)
   • Continue topical therapies

4. Severe or Refractory AD:

   • Systemic therapy with dupilumab, tralokinumab, or JAK inhibitors
   • Alternative options include azathioprine, cyclosporine, methotrexate, or mycophenolate

Common Pitfalls and Caveats

• Overuse of topical corticosteroids: Can lead to skin atrophy, telangiectasia, and tachyphylaxis. Use appropriate potency for the affected area and limit treatment duration.

• Underuse of emollients: Many patients focus only on anti-inflammatory treatments during flares but neglect daily emollient use, which is crucial for barrier repair.

• Inappropriate use of systemic corticosteroids: Despite common use in clinical practice, systemic corticosteroids should be avoided due to rebound flares and significant side effects 5.

• Delayed escalation of therapy: Patients with inadequate response to topical therapies should be promptly considered for phototherapy or systemic agents to prevent chronic disease and impaired quality of life 6.

• Overlooking secondary infections: Consider antistaphylococcal antibiotics when secondary skin infections are present 7.