What is the treatment for atopic dermatitis on the scalp?

Treatment of Atopic Dermatitis on the Scalp

Medium-potency topical corticosteroids are the first-line treatment for atopic dermatitis on the scalp, applied once daily for 2-4 weeks, followed by topical calcineurin inhibitors for maintenance therapy. 1

First-Line Treatment

• Initial therapy: Medium-potency topical corticosteroids

  • Apply once daily for 2-4 weeks to affected areas of the scalp
  • For moderate to severe cases, consider high-potency corticosteroids for the acute phase 1
  • Limit duration to avoid side effects such as skin atrophy, which can occur after just 2 weeks of treatment 2

• Application schedule for moderate-severe cases:

  • Initial phase: Once daily for 4 weeks
  • Tapering phase: Alternate days for 4 weeks
  • Maintenance phase: Twice weekly for 4 weeks before reassessment 1

Maintenance Therapy

• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) are recommended for maintenance after disease stabilization 3, 1

  • Apply 2-3 times per week to previously affected areas 3
  • These agents do not cause skin atrophy, making them safer for long-term use 2
  • Tacrolimus 0.03% is approved for children ≥2 years old 1
  • Pimecrolimus 1% cream is indicated as second-line therapy for mild to moderate atopic dermatitis in patients 2 years and older 4

• Alternating therapy approach:

  • For moderate to severe cases, consider alternating between topical corticosteroids (weekends) and tacrolimus (weekdays) to reduce corticosteroid side effects while maintaining control 1

Adjunctive Measures

• Emollient therapy:

  • Use fragrance-free emollients liberally and frequently (3-8 times daily)
  • Apply immediately after washing to trap moisture
  • Continue even when skin appears normal 1

• Cleansing:

  • Use soap-free cleansers for washing the scalp 5
  • Avoid irritants and harsh shampoos

• Infection prevention:

  • Keep crusted or eroded lesions clean
  • For suspected bacterial infections, obtain cultures and consider topical antibiotics 1
  • Bleach baths with 0.005% sodium hypochlorite twice weekly can help prevent infections 1

When to Consider Advanced Therapies

• Phototherapy:

  • Consider for moderate to severe cases that don't respond to topical treatments 5, 6
  • PUVA has shown superior efficacy to UVB for resistant cases 1

• Systemic therapy:

  • Reserved for severe cases unresponsive to topical treatments
  • Options include oral corticosteroids (short course), cyclosporine, methotrexate, or newer biologics like dupilumab 1, 6

Important Considerations

• Monitoring: Watch for signs of skin atrophy, which can occur with topical corticosteroids after just 2 weeks of use 2

• Efficacy comparison: Studies show that tacrolimus 0.03% applied twice daily is more effective than 1% hydrocortisone acetate for moderate to severe atopic dermatitis, with a 76.7% vs 47.6% reduction in severity scores 7

• Application frequency: While twice-daily application of hydrocortisone is beneficial on the first day of treatment, once-daily application may be sufficient from the second day onward as the skin barrier begins to restore 8

• Referral indications:

  • Diagnostic uncertainty
  • Poor response to initial treatment
  • Severe or widespread disease requiring systemic therapy 1

Remember that continued use of either topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) after disease stabilization is recommended to reduce subsequent flares or relapses 3.