What are the treatment options for atopic dermatitis?

Treatment Options for Atopic Dermatitis

For patients with atopic dermatitis, a stepwise approach starting with topical therapies and progressing to phototherapy and systemic agents is strongly recommended based on disease severity and response to treatment. 1

First-Line Treatments

• Moisturizers/Emollients are essential front-line therapy for both acute treatment and maintenance, recommended for application after bathing 1
• Topical Corticosteroids (TCS) are first-line pharmacologic therapy when nonpharmacologic interventions are insufficient 1
  • Use with caution in thinned-skin areas 1
  • Continue use 1-2× per week on previously involved skin after disease stabilization to prevent flares 2
• Topical Calcineurin Inhibitors (TCI) such as tacrolimus and pimecrolimus are effective steroid-sparing agents for both acute and maintenance therapy 1, 3
  • Can be used 2-3× per week on previously involved skin for maintenance 2
  • Consider preceding use with TCS to reduce severity of cutaneous reactions 1

Second-Line Treatments

Phototherapy

• Strongly recommended for recalcitrant AD after failure of first-line topical treatments 1
• Narrowband UVB is generally preferred over other modalities due to efficacy, safety profile, and availability 1
• Potential adverse effects include sunburn-like reactions, heat intolerance, and long-term skin cancer risk (especially with PUVA) 1
• Major limitation is accessibility as most regimens require treatments 2-3 times weekly for 10-14 weeks 1

Systemic Therapies

For moderate-to-severe AD not adequately controlled with topical treatments and phototherapy:

Strong Recommendations:

• Dupilumab - FDA-approved for moderate-to-severe AD in patients 6 months and older 1, 4
  • Administered by subcutaneous injection with dosing based on age and weight 4
  • Can be used with or without topical corticosteroids 4
• Tralokinumab - strongly recommended for moderate-to-severe AD 1
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib) - strongly recommended for moderate-to-severe AD 1

Conditional Recommendations:

• Cyclosporine (1-4 mg/kg/day) - conditionally recommended for severe chronic AD 1, 2
• Methotrexate - conditionally recommended 1
• Azathioprine - conditionally recommended 1
• Mycophenolate - conditionally recommended 1

Not Recommended:

• Systemic corticosteroids are conditionally recommended against due to risk of rebound flares and serious adverse events, even with short-term use 1
  • May be considered only in limited circumstances as a bridge to other long-term therapies 1

Adjunctive Treatments

• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection, not for non-infected AD 1, 2
• Systemic antiviral agents should be used for eczema herpeticum 1, 2
• Antihistamines:
  • Short-term, intermittent use of sedating antihistamines may help with sleep disturbance due to itch 1
  • Non-sedating antihistamines are not recommended for routine treatment of AD unless the patient also has urticaria or rhinoconjunctivitis 1
• Educational interventions (training programs, "eczema schools") are beneficial as adjuncts to conventional therapy 2

Common Pitfalls to Avoid

• Relying on antihistamines as primary treatment for itch - they are not effective for AD-related pruritus 2, 5
• Using systemic antibiotics without evidence of infection - inappropriate use contributes to antibiotic resistance 1, 2
• Discontinuing topical therapy completely after resolution of acute flares - maintenance therapy is crucial to prevent recurrence 2
• Undertreatment due to "steroid phobia" - appropriate use of TCS is safe and effective 1
• Overuse of systemic corticosteroids - can lead to rebound flares and significant adverse effects 1

Treatment Algorithm

1. Mild AD: Emollients + low-potency TCS or TCI 1, 5
2. Moderate AD: Emollients + medium-potency TCS or TCI; consider proactive maintenance therapy 1, 5
3. Severe or Refractory AD: Add phototherapy (preferably narrowband UVB) 1
4. Very Severe or Phototherapy Failure: Add systemic therapy, with dupilumab, tralokinumab, or JAK inhibitors as preferred options 1, 4
5. Alternative Systemic Options: Consider cyclosporine, methotrexate, azathioprine, or mycophenolate if biologics/JAK inhibitors are unavailable or contraindicated 1

The treatment of atopic dermatitis requires a stepwise approach, with careful consideration of disease severity, patient age, affected areas, and response to previous treatments to optimize outcomes and minimize adverse effects.