What is the recommended treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

The recommended treatment for atopic dermatitis follows a stepwise approach, starting with topical therapies (moisturizers and topical corticosteroids), followed by phototherapy, and systemic agents for refractory cases. 1

First-Line Treatment

Basic Skin Care

• Moisturizers/emollients are foundational therapy for all patients with atopic dermatitis
• Apply immediately after bathing to improve skin barrier function
• Use soap-free cleansers for daily bathing 1, 2

Acute Flare Management

• Topical corticosteroids (TCS) are the primary pharmacologic treatment for flares 1

  • Select potency based on:
    • Disease severity
    • Body location (lower potency for face, neck, intertriginous areas)
    • Patient age
  • Apply twice daily until flare resolves

• Topical calcineurin inhibitors (TCIs) such as tacrolimus and pimecrolimus are recommended alternatives 1

  • Particularly useful for sensitive areas where TCS may cause atrophy
  • Pimecrolimus 1% cream is FDA-approved as second-line therapy for mild to moderate atopic dermatitis in patients 2 years and older 3
  • TCIs do not cause skin atrophy, making them safer for facial use 4

Maintenance Therapy

After disease stabilization, proactive maintenance therapy is strongly recommended:

• TCS: Apply 1-2 times weekly to previously affected areas
• TCIs: Apply 2-3 times weekly to previously affected areas 1

Second-Line Treatment

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 1, 5

Third-Line Treatment (Severe Disease)

Systemic Therapies

For patients with inadequate response to topical therapies and phototherapy:

Strongly recommended options:

• Biologics: dupilumab, tralokinumab
• JAK inhibitors: abrocitinib, baricitinib, upadacitinib 1, 6

Conditionally recommended options:

• Azathioprine
• Cyclosporine
• Methotrexate
• Mycophenolate 1

Not recommended:

• Systemic corticosteroids (risk of rebound flares upon discontinuation) 1

Special Considerations

Pediatric Patients

• Pimecrolimus is FDA-approved for children 2 years and older 3
• Children <5 years with moderate-severe atopic dermatitis should be considered for food allergy evaluation only if:
  • AD persists despite optimized treatment
  • There is a reliable history of immediate reaction after food ingestion 1

Secondary Infections

• Antistaphylococcal antibiotics for treating secondary skin infections 2
• Bleach baths may be beneficial during flares 6

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids: Even mild potency corticosteroids like hydrocortisone 1% can cause epidermal thinning after just 2 weeks of continuous use 4

2. Inappropriate allergy testing: Not recommended without specific history suggesting allergies 1

3. Food elimination diets: Not recommended based solely on allergy test results 1

4. Reliance on antihistamines: Oral antihistamines are not recommended for treating pruritus in atopic dermatitis, though they may help with sleep 2, 6

5. Routine use of topical antimicrobials: Not recommended unless there is clinical evidence of infection 1