What is the recommended treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

The recommended treatment for atopic dermatitis follows a stepwise approach, starting with topical therapies including moisturizers and topical corticosteroids as first-line treatment, followed by topical calcineurin inhibitors, with systemic therapies and biologics reserved for moderate to severe cases that don't respond to topical treatments. 1

First-Line Treatments

• Moisturizers/Emollients: Should be used liberally and regularly as the foundation of atopic dermatitis management to maintain skin hydration and barrier function 1, 2

• Bathing: Regular bathing with soap-free cleansers is recommended, followed by immediate application of moisturizers 1, 3

• Topical Corticosteroids (TCS): First-line pharmacologic treatment for active inflammation and flares, with strength selected based on severity and body location 1, 3

  • Low-potency TCS (e.g., hydrocortisone 1%) for sensitive areas like face, neck, and intertriginous areas 3
  • Medium to high-potency TCS for trunk and extremities 1
  • Maintenance therapy with intermittent application (1-2× weekly) to previously affected areas can prevent flares 2

• Topical Calcineurin Inhibitors (TCIs): Recommended as first-line therapy, particularly for sensitive skin areas where TCS may cause atrophy 1, 4

  • Pimecrolimus 1% cream for mild to moderate atopic dermatitis in patients ≥2 years old 4
  • Tacrolimus has shown superior efficacy compared to hydrocortisone in pediatric patients 5, 6
  • TCIs don't cause skin atrophy, making them safer for long-term use, especially on the face 7

Second-Line Treatments

• Topical PDE-4 Inhibitors: Strongly recommended for atopic dermatitis management 1
• Topical JAK Inhibitors: Strongly recommended for atopic dermatitis management 1
• Wet Wrap Therapy: Can be used for acute flares to enhance penetration of topical medications and provide barrier protection 1, 2

Treatment for Moderate to Severe Disease

• Phototherapy: Recommended when topical therapies fail to control symptoms, particularly narrowband UVB 1

  • Consider for adults with inadequate response to optimized topical treatments 8
  • Various forms are beneficial including NB-UVB, BB-UVB, UVA, and PUVA 1

• Systemic Therapies: Indicated when optimized topical regimens and/or phototherapy fail to control symptoms 1

  • Biologics: Strong recommendations for dupilumab and tralokinumab 1
  • JAK Inhibitors: Strong recommendations for abrocitinib, baricitinib, and upadacitinib 1
  • Traditional Immunomodulators: Conditional recommendations for:
    • Cyclosporine (1-4 mg/kg/day) - effective for refractory atopic dermatitis 1, 2
    • Azathioprine - recommended for refractory cases 1
    • Methotrexate (7.5-25mg/week) - recommended with folate supplementation 1
    • Mycophenolate mofetil - may be considered as alternative therapy 1

Adjunctive Treatments

• Antihistamines: Not recommended for routine treatment of atopic dermatitis, but sedating antihistamines may help with sleep disturbance due to itch 1, 3
• Antimicrobials: Systemic antibiotics should only be used when there is clinical evidence of bacterial infection, not for non-infected atopic dermatitis 1, 2
• Antiviral Agents: Recommended for treating eczema herpeticum 1, 2

Treatments Not Recommended

• Systemic Corticosteroids: Should be avoided if possible; use should be exclusively reserved for acute, severe exacerbations and as short-term bridge therapy 1
• Topical Antimicrobials/Antiseptics: Conditional recommendation against routine use 1
• Topical Antihistamines: Conditional recommendation against use 1

Common Pitfalls to Avoid

• Relying on antihistamines as primary treatment for itch rather than addressing inflammation 1, 2
• Using systemic antibiotics without evidence of infection 1, 2
• Discontinuing topical therapy completely after resolution of acute flares instead of transitioning to maintenance therapy 2
• Using potent topical corticosteroids on sensitive areas like the face for prolonged periods, which can cause skin atrophy 7
• Neglecting the importance of consistent moisturizer use as the foundation of therapy 1, 3