What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

The cornerstone treatment for atopic dermatitis includes topical corticosteroids for acute flares, with topical calcineurin inhibitors as alternatives for sensitive areas, along with consistent use of emollients and proper skin care techniques. 1

First-Line Treatments

Prevention of Flares

• Continued use of topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously involved skin after disease stabilization is recommended to prevent flares 1
• Regular use of emollients and moisturizers is essential for maintaining skin barrier function 2
• Educational interventions (training programs, "eczema schools") are beneficial as adjuncts to conventional therapy 1

Acute Management

• Topical corticosteroids are first-line treatment for flares, with strength selection based on affected body area 3
  • Lower potency for face, neck, intertriginous areas
  • Higher potency for trunk and extremities
• Topical calcineurin inhibitors (pimecrolimus, tacrolimus) are effective alternatives, particularly for sensitive areas where corticosteroids may cause adverse effects 4, 3
• Pimecrolimus cream 1% shows significant improvement in erythema and infiltration/papulation by day 8 of treatment 4

Second-Line and Adjunctive Treatments

Phototherapy

• Ultraviolet phototherapy is recommended for moderate to severe atopic dermatitis when first-line treatments are inadequate 3
• Should be administered under specialist supervision 5

Systemic Treatments

• Systemic antibiotics are appropriate only for patients with clinical evidence of bacterial infections 1
• Systemic antiviral agents should be used for eczema herpeticum 1
• For severe chronic atopic dermatitis:
  • Dupilumab is indicated for moderate-to-severe atopic dermatitis in patients aged 6 months and older whose disease is not adequately controlled with topical therapies 6
  • Traditional immunosuppressants like cyclosporine (1-4 mg/kg/day) may be considered 1, 5

Antihistamines

• There is insufficient evidence to recommend the general use of antihistamines for atopic dermatitis 1
• Short-term, intermittent use of sedating antihistamines may be beneficial for sleep disturbance due to itch, but should not replace proper management with topical therapies 1
• Non-sedating antihistamines are not recommended as routine treatment in the absence of urticaria or other atopic conditions 1

Adjunctive Approaches

Allergy Management

• Allergy testing should only be performed when there are specific concerns identified during history taking 1
• Food elimination diets based solely on allergy test results are not recommended 1
• Children under 5 years with moderate to severe atopic dermatitis should be considered for food allergy evaluation only if they have:
  • Persistent atopic dermatitis despite optimized treatment, or
  • A reliable history of immediate reaction after food ingestion 1
• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 1

Interventions Not Recommended

• Systemic antibiotics for non-infected atopic dermatitis 1
• Probiotics/prebiotics for established atopic dermatitis 1
• Dietary supplements including fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12, and B6 1
• Sublingual or injection immunotherapy 1
• Alternative therapies such as Chinese herbal therapy, massage therapy, aromatherapy, naturopathy, hypnotherapy, acupressure, or autologous blood injections 1

Treatment Algorithm

1. Basic therapy (all patients):

   • Daily bathing with soap-free cleansers
   • Liberal use of emollients
   • Identification and avoidance of triggers 3

2. For mild flares:

   • Low to medium potency topical corticosteroids twice daily until resolution
   • Topical calcineurin inhibitors for sensitive areas 3

3. For moderate flares:

   • Medium to high potency topical corticosteroids
   • Consider wet wrap therapy for enhanced penetration 3

4. For severe or widespread disease:

   • Consider referral to dermatologist
   • Phototherapy may be indicated
   • Dupilumab or other systemic agents for refractory cases 6, 5

5. Maintenance therapy:

   • Proactive application of topical anti-inflammatory agents (1-3× weekly) to previously affected areas
   • Continued daily emollient use 1, 2

Common Pitfalls to Avoid

• Relying on antihistamines as primary treatment for itch 1
• Using systemic antibiotics without evidence of infection 1
• Recommending elimination diets based solely on allergy testing 1
• Discontinuing topical therapy completely after resolution of acute flares, rather than transitioning to maintenance therapy 1
• Neglecting the importance of patient education in disease management 1