What is the recommended treatment for atopic dermatitis affecting the bilateral thigh, groin, and axillary (underarm) areas?

Treatment of Atopic Dermatitis on Bilateral Thigh, Groin, and Underarms

For atopic dermatitis affecting the bilateral thigh, groin, and axillary areas, a stepwise approach is recommended starting with moisturizers and topical corticosteroids, with consideration for topical calcineurin inhibitors particularly for sensitive areas like the groin and axillae. 1, 2

First-Line Treatment

Moisturizers and Bathing

• Moisturizers should be applied liberally after bathing to hydrate the skin and repair the skin barrier 1, 2
• Bathing with a gentle, soap-free cleanser is recommended for cleansing and hydrating the skin 1
• A dispersible cream should be used as a soap substitute to cleanse the skin, as soaps and detergents remove natural lipids from the skin surface 1

Topical Corticosteroids (TCS)

• Medium-potency topical corticosteroids are recommended for the thighs 1, 2
• Lower-potency topical corticosteroids should be used for the groin and axillary regions due to increased absorption in these areas 1, 2
• Apply TCS twice daily during flares until improvement is seen 1
• After disease stabilization, intermittent use of medium-potency TCS (2 times/week) is strongly recommended as maintenance therapy to prevent flares 1

Topical Calcineurin Inhibitors (TCIs)

• TCIs are particularly valuable for sensitive areas like the groin and axillae where skin atrophy from topical steroids is a concern 1, 2
• Tacrolimus 0.1% ointment is strongly recommended for adults with AD affecting sensitive areas 1, 3
• Pimecrolimus 1% cream is strongly recommended for mild-to-moderate AD 1, 4
• Apply TCIs twice daily until improvement, then reduce to maintenance therapy (2-3 times/week) 1, 4
• TCIs should not be used under occlusion, which may increase systemic absorption 4

Important Considerations for Sensitive Areas

Groin and Axillary Regions

• These areas are more prone to maceration, secondary infection, and increased absorption of topical medications 1
• Avoid potent topical corticosteroids in these areas to prevent skin atrophy and striae 1, 2
• TCIs are preferred for long-term management of these sensitive areas 1, 2
• Keep these areas clean and dry to prevent secondary infections 1

Adjunctive Therapies

For Flares with Significant Inflammation

• Wet wrap therapy can be conditionally recommended for moderate-to-severe flares 1
• Apply moisturizer or medication, then cover with a layer of wet gauze followed by a dry layer 1

For Pruritus (Itching)

• Sedating antihistamines may be useful as a short-term adjuvant during severe itching episodes, primarily for their sedative properties 1
• Non-sedating antihistamines have little value in atopic dermatitis 1
• Topical antihistamines are conditionally recommended against due to limited evidence 1

For Secondary Infection

• Topical antimicrobials are conditionally recommended against for routine use 1
• If clinical signs of secondary bacterial infection are present, consider bleach baths or topical sodium hypochlorite 1
• Systemic antibiotics should only be used when there is clear evidence of bacterial infection 2

Prevention of Flares

• Proactive maintenance therapy with twice-weekly application of TCS or TCIs to previously affected areas is strongly recommended to prevent flares 1
• Avoid known triggers such as irritants, extreme temperatures, and stress 1
• Wear cotton clothing rather than wool or synthetic fabrics, especially in direct contact with the skin 1

When to Consider Escalating Therapy

• If inadequate response to optimized topical therapy after 4-8 weeks 1
• If extensive body surface area is affected 1
• If quality of life is significantly impaired 1
• Consider referral for phototherapy or systemic therapy in these cases 1

Common Pitfalls to Avoid

• Undertreatment due to steroid phobia - explain the appropriate use and safety of topical corticosteroids when used correctly 1
• Using potent steroids in sensitive areas like the groin and axillae, which can lead to skin atrophy 1, 5
• Discontinuing treatment too early once improvement is seen, rather than transitioning to maintenance therapy 1
• Failing to address secondary bacterial infections which can exacerbate atopic dermatitis 1
• Using systemic corticosteroids, which are not recommended for long-term management of atopic dermatitis due to rebound flares upon discontinuation 1, 5