What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

For atopic dermatitis treatment, a stepwise approach is strongly recommended, starting with topical therapies, followed by phototherapy, and then systemic agents for refractory cases, with moisturizers/emollients as foundational therapy for all patients. 1

First-Line Therapy: Topical Treatments

Foundational Therapy

• Emollients/moisturizers: Essential for all patients regardless of disease severity
  • Reduce signs, symptoms, and inflammation
  • Improve severity and increase time between flare-ups
  • Can be used as monotherapy in mild cases 1

Acute Flare Management

1. Topical corticosteroids (TCS):

   • Primary pharmacological treatment for flare-ups
   • Select potency based on:
     • Disease severity
     • Body location (lower potency for face, neck, intertriginous areas)
     • Patient age 1

2. Topical calcineurin inhibitors (TCIs):

   • Alternatives to TCS for sensitive areas like face and neck
   • Options include tacrolimus and pimecrolimus
   • Pimecrolimus is indicated for short-term and non-continuous long-term treatment of mild to moderate atopic dermatitis in patients over 2 years old 1, 2

3. Proactive maintenance therapy (after disease stabilization):

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

4. Additional topical options:

   • Phosphodiesterase-4 inhibitors (crisaborole) 3
   • Wet wraps during flare-ups (conditional recommendation) 1

Second-Line Therapy: Phototherapy

• UVB narrowband phototherapy: Preferred modality for patients with inadequate response to optimized topical regimens
  • Typically requires 2-3 sessions per week initially
  • Potential adverse effects include sunburn-like reactions and heat intolerance
  • Long-term risk of skin cancer (higher with PUVA than other modalities) 4, 1
  • Limited by accessibility issues 4

Third-Line Therapy: Systemic Treatments

Strongly Recommended Options

• Biologics:

  • Dupilumab
  • Tralokinumab 4, 1

• JAK inhibitors:

  • Abrocitinib
  • Baricitinib
  • Upadacitinib 4, 1

Conditionally Recommended Options

• Immunomodulators:
  • Azathioprine
  • Cyclosporine
  • Methotrexate
  • Mycophenolate 4, 1

Not Recommended

• Systemic corticosteroids: Conditional recommendation against use due to risk of rebound flares upon discontinuation 4, 1

Management of Complications

Infection Management

• Bacterial infections:

  • Systemic antibiotics only when clinical evidence of bacterial infection exists
  • Routine use of topical antimicrobials not recommended 1
  • Antiseptic baths may be considered during flare-ups 1

• Viral infections:

  • Systemic antivirals for eczema herpeticum 1

Pruritus Management

• Antihistamines:
  • Sedating antihistamines: May help with sleep disturbances from pruritus (short-term use)
  • Non-sedating antihistamines: Not recommended as routine treatment 1

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 flares
   • TCIs for sensitive areas
   • Proactive maintenance therapy
   • Consider phototherapy if inadequate response

3. Severe AD:

   • Daily emollients/moisturizers
   • High-potency TCS for flares (short-term)
   • TCIs for sensitive areas
   • Phototherapy
   • If inadequate response, add systemic therapy:
     • First options: Dupilumab, tralokinumab, or JAK inhibitors
     • Alternative options: Azathioprine, cyclosporine, methotrexate, or mycophenolate

Important Considerations

• The decision to initiate advanced therapies should involve shared decision-making between patients and clinicians 4
• Most patients will use evidence-based topical therapies concomitantly with phototherapy and systemic therapies 4
• When AD is refractory to standard treatments, consider alternative diagnoses such as allergic contact dermatitis and cutaneous lymphoma 4
• Educational programs ("eczema schools") are recommended as adjuncts to conventional therapy 1
• Allergy testing is not recommended without specific history suggesting allergies 1