What is the treatment for atopic dermatitis in a patient with bumps around the hairline and a non-productive cough, possibly related to asthma?

Treatment for Atopic Dermatitis

The treatment for atopic dermatitis should include topical corticosteroids as first-line therapy for acute flares, with daily emollients and avoidance of triggers as the cornerstone of maintenance therapy. 1

First-Line Treatment Approach

Topical Therapies

• Topical corticosteroids:

  • Use high-potency corticosteroids for acute phase (2-4 weeks)
  • Medium-potency for longer treatments
  • Low-potency for mild cases and sensitive areas like the face/hairline 1
  • Apply twice daily to affected areas during flares

• Moisturizers/Emollients:

  • Apply alcohol-free moisturizers liberally and frequently (3-8 times daily)
  • Use immediately after bathing to trap moisture
  • Continue even when skin appears normal
  • Choose fragrance-free products 1

Skin Care Practices

• Avoid excessive washing with hot water
• Do not use alcohol-based products, solvents, or disinfectants
• Use gentle, soap-free cleansers for bathing 1

Second-Line Treatments

Topical Calcineurin Inhibitors

• Pimecrolimus (Elidel) 1% cream:

  • Approved for patients 2 years and older with mild to moderate atopic dermatitis
  • Apply a thin layer to affected areas twice daily
  • Particularly useful for face, neck, and intertriginous areas where corticosteroids may cause atrophy 2
  • Improvement in symptoms typically seen by day 15 2
  • May cause local burning sensation or pruritus, especially during first few days of application 2

• Tacrolimus ointment:

  • 0.03% for children 2-15 years old
  • 0.1% for adults
  • More effective than weak corticosteroids for moderate cases 3

Management of Infections and Complications

• For bacterial infections:

  • Obtain bacterial cultures before starting antibiotics
  • Apply topical antibiotics as directed
  • Consider oral antibiotics (e.g., doxycycline 100 mg twice daily for 7-14 days) for more extensive infections 1
  • Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent recurrent infections 1

• For viral skin infections:

  • Resolve bacterial or viral infections at treatment sites before starting therapy
  • Be vigilant for signs of eczema herpeticum, which requires prompt antiviral treatment 2

Advanced Therapies for Moderate-to-Severe Disease

Systemic Treatments

• Systemic corticosteroids:

  • Limited role in severe acute flares
  • Not recommended for maintenance therapy
  • If used, prednisone 1 mg/kg/day with tapering over at least 4 weeks 1

• Biologics and immunomodulators:

  • Dupilumab for moderate-to-severe cases unresponsive to topical therapies
  • JAK inhibitors (abrocitinib, baricitinib, upadacitinib)
  • Traditional immunomodulators (cyclosporine, methotrexate, azathioprine, mycophenolate mofetil) 1

Phototherapy

• Consider for moderate-to-severe cases not responding to topical treatments
• PUVA (Psoralen + UVA) has shown superior efficacy to UVB for hand eczema 1

Special Considerations for This Patient

• For the bumps around the hairline:

  • Rule out secondary bacterial infection (consider bacterial culture)
  • Apply medium-potency topical corticosteroid twice daily for 2 weeks
  • Consider pimecrolimus if the area is sensitive or if concerned about steroid side effects 2

• Given the patient's asthma and cough:

  • Be aware of the atopic march (relationship between atopic dermatitis, asthma, and allergic rhinitis)
  • Ensure proper asthma management as respiratory symptoms may worsen during atopic dermatitis flares
  • Consider environmental triggers that might be exacerbating both conditions 1

Common Pitfalls to Avoid

• Overuse of topical corticosteroids: Limit high-potency corticosteroids to 2-4 weeks to avoid skin atrophy and other side effects 1

• Inadequate moisturizer use: Many patients underestimate the importance of regular emollient application, which is crucial for skin barrier repair 1

• Ignoring infections: Secondary bacterial infections are common in atopic dermatitis and require prompt treatment 1

• Continuous use of calcineurin inhibitors: Pimecrolimus should be used for short periods with breaks in between treatments 2

• Missing trigger factors: Identifying and avoiding triggers is essential for long-term management 1