What is the treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

The first-line treatment for atopic dermatitis consists of emollients to restore skin barrier function, followed by topical corticosteroids for inflammation when flares occur, with treatment escalation to phototherapy and systemic agents for refractory cases. 1

Step-by-Step Treatment Algorithm

First-Line Therapy

1. Basic Therapy (Daily Maintenance)

   • Emollients/Moisturizers: Apply liberally multiple times daily to maintain skin barrier function
   • Trigger avoidance: Identify and eliminate exacerbating factors
   • Education: Comprehensive patient/caregiver education on proper skin care

2. Reactive Therapy (For Flares)

   • Topical Corticosteroids (TCS):
     • Select potency based on severity, location, and patient age
     • Low potency for face, neck, skin folds, and in infants
     • Medium to high potency for other body areas in older children/adults
     • Apply thinly to affected areas only for short courses (5-7 days) 1
     • Avoid high-potency TCS on sensitive areas to prevent skin atrophy 1

Second-Line Therapy

1. Topical Calcineurin Inhibitors (TCIs)

   • Pimecrolimus 1% cream: For patients ≥3 months, especially for sensitive areas 2, 1
   • Tacrolimus ointment: For moderate-to-severe AD

2. Topical PDE-4 Inhibitor

   • Crisaborole: Alternative for patients ≥3 months 1

3. Proactive Therapy

   • Apply low-medium potency TCS 2-3 times weekly to previously affected areas to prevent flares 1

Third-Line Therapy (For Moderate-to-Severe Disease)

1. Phototherapy

   • Narrowband UVB: Preferred modality, typically 2-3 sessions per week initially 3, 1
   • Recommended after failure of first-line treatments 3
   • Not recommended for children younger than 12 years 1

2. Systemic Therapy

   • Dupilumab: FDA approved for moderate-to-severe AD in patients ≥6 months 4, 1
   • Cyclosporine: 3-6 mg/kg/day divided into two doses, limited to 3-6 months due to side effects 3, 1
   • Methotrexate: 7.5-25 mg/week 3
   • Azathioprine: 1-3 mg/kg/day, dosing guided by TPMT enzyme activity 3
   • Systemic corticosteroids: Not recommended due to risk of rebound flares upon discontinuation 1

Special Considerations

Antihistamines and Antimicrobials

• Antihistamines:

  • Insufficient evidence for routine use in AD 3
  • Short-term, intermittent use of sedating antihistamines may help with sleep loss due to itch 3
  • Non-sedating antihistamines not recommended unless patient has comorbid urticaria or allergic rhinoconjunctivitis 3

• Systemic antibiotics:

  • Not recommended for non-infected AD 3
  • Appropriate only for clinical evidence of bacterial infection 3
  • Systemic antiviral agents should be used for eczema herpeticum 3

Monitoring and Follow-up

• Assess response to treatment within 2-4 weeks 1
• For systemic therapies:
  • Cyclosporine: Monitor creatinine; if increases >25% above baseline, reduce dose 3
  • Methotrexate: Monitor liver enzymes; discontinue if exceeding 5× normal 3

Treatment Challenges and Pitfalls

1. Inadequate moisturization: Many treatment failures occur due to insufficient use of emollients. Ensure liberal application multiple times daily.

2. Steroid phobia: Fear of topical corticosteroid side effects can lead to undertreatment. Educate patients on proper use and safety when used appropriately.

3. Incorrect potency selection: Using too low potency for severe areas or too high potency on sensitive areas. Match potency to location and severity.

4. Abrupt discontinuation: Tapering topical corticosteroids can prevent rebound flares.

5. Missing secondary infection: Always assess for bacterial, viral, or fungal superinfection when AD suddenly worsens.

6. Overlooking triggers: Environmental factors, allergens, stress, and irritants can perpetuate disease. Identification and avoidance are crucial.

7. Delayed escalation: Timely referral to specialists for consideration of phototherapy or systemic therapy when first-line treatments fail can prevent unnecessary suffering.

By following this structured approach to AD management, clinicians can effectively control symptoms, prevent flares, and improve patients' quality of life while minimizing treatment-related adverse effects.