What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

The most effective treatment approach for atopic dermatitis involves a stepwise algorithm starting with basic skin care and topical therapies, progressing to phototherapy and systemic treatments for more severe cases. 1

Basic Skin Care (All Patients)

• Daily emollient therapy: Apply fragrance-free emollients 3-8 times daily, even when skin appears normal
• Proper bathing: Use soap-free cleansers followed by immediate moisturizer application
• Trigger avoidance: Identify and eliminate triggering substances

Treatment Algorithm Based on Severity

Mild Atopic Dermatitis

• First-line: Low-potency topical corticosteroids (TCS) (e.g., hydrocortisone 1%) twice daily for 1-2 weeks 1
• For sensitive areas (face, neck, intertriginous areas):
  • Topical calcineurin inhibitors (TCIs) like pimecrolimus 1% cream 2
  • Low-potency TCS with caution

Moderate Atopic Dermatitis

• First-line: Moderate-potency TCS twice daily for 2-4 weeks 1
• For sensitive areas: TCIs preferred over TCS 1
• Additional options:
  • Topical PDE-4 inhibitors (crisaborole)
  • Topical JAK inhibitors

Severe Atopic Dermatitis

• First-line: High-potency TCS twice daily for up to 4 weeks 1
• For sensitive areas: TCIs 1
• If inadequate response:
  • Phototherapy (narrowband UVB) 3, 1
  • Systemic therapies:
    • Biologics: Dupilumab for patients ≥6 months old with moderate-to-severe disease 4
    • Oral JAK inhibitors: Abrocitinib, baricitinib, upadacitinib 1
    • Traditional immunomodulators: Cyclosporine, methotrexate, azathioprine, mycophenolate mofetil 3, 1

Flare Prevention Strategies

• Proactive therapy: Apply TCS 1-2 times weekly or TCIs 2-3 times weekly to previously affected areas after clearing to prevent flares 3, 5
• Bleach baths: 0.005% sodium hypochlorite twice weekly to prevent infections 1
• Environmental modifications: Consider air purifiers, reduce PM 2.5 exposure 1

Management of Complications

Infection

• For clinically evident infections:
  • Antiseptic washes with aqueous chlorhexidine 0.05% for erosive lesions 1
  • Appropriate antibiotics when indicated

Severe Pruritus

• Oral antihistamines may help with sleep disturbance but have limited effect on daytime pruritus 6

Special Considerations

Allergic Contact Dermatitis

• Patch testing should be considered for patients with persistent/recalcitrant disease 3, 1

Food Allergies

• Food elimination diets based solely on allergy test results are not recommended 3
• Children <5 years with moderate-to-severe AD should be considered for food allergy evaluation if they have persistent AD despite optimal treatment or immediate reactions after food ingestion 3

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids: Can lead to skin atrophy, striae, and tachyphylaxis
2. Undertreatment: Using inadequate potency or duration of therapy
3. Neglecting maintenance therapy: Failing to continue emollients between flares
4. Inappropriate food elimination: Restricting diet based solely on allergy tests without clinical correlation
5. Delayed escalation of therapy: Not advancing to systemic treatments when appropriate for severe disease 7

When to Refer to a Specialist

• Diagnostic uncertainty
• Failure to respond to appropriate topical treatments
• Need for systemic therapy or phototherapy
• Significant psychosocial impact 1

The treatment of atopic dermatitis has evolved significantly with newer targeted therapies like dupilumab showing excellent efficacy for moderate-to-severe disease 4, 6. However, the foundation of management remains proper skin care, appropriate use of topical anti-inflammatory agents, and identification of individual triggers.