What is the medical management for atopic dermatitis?

Medical Management for Atopic Dermatitis

The medical management of atopic dermatitis requires a stepwise approach starting with topical therapies (moisturizers, topical corticosteroids, and calcineurin inhibitors) as first-line treatments, progressing to phototherapy for moderate cases, and advancing to systemic therapies like dupilumab or JAK inhibitors for severe disease. 1

First-Line Treatments

Basic Skin Care

• Moisturizers/emollients are essential front-line therapy for both acute treatment and maintenance, recommended for application after bathing 1
• Daily bathing with soap-free cleansers helps maintain skin hydration 2
• Educational interventions such as training programs and "eczema schools" are beneficial adjuncts to conventional therapy 3

Topical Anti-inflammatory Treatments

• Topical corticosteroids (TCS) are first-line pharmacologic therapy when nonpharmacologic interventions are insufficient 1
  • Select appropriate potency based on disease severity and body location 4
  • Limit to intermittent short-term use for active inflammation 5
• Topical calcineurin inhibitors (TCI) such as tacrolimus and pimecrolimus are effective steroid-sparing agents 1
  • Particularly useful for sensitive areas like face, neck, and intertriginous areas 6
• Topical phosphodiesterase-4 inhibitors (e.g., crisaborole) can be used for widespread involvement 5

Maintenance Therapy

• Continued use of topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously involved skin after disease stabilization prevents flares 3
• Noncorticosteroid topical maintenance therapy should continue to prevent flares and reduce the need for TCS 5

Second-Line Treatments

Phototherapy

• Narrowband UVB is recommended for recalcitrant atopic dermatitis after failure of first-line topical treatments 1
• Preferred over other phototherapy modalities due to efficacy, safety profile, and availability 1

Systemic Therapies

• Dupilumab is FDA-approved for moderate-to-severe atopic dermatitis in patients 6 months and older 7
• Tralokinumab is strongly recommended for moderate-to-severe atopic dermatitis 1
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib) are strongly recommended for moderate-to-severe atopic dermatitis 1
• Traditional immunosuppressants like cyclosporine (1-4 mg/kg/day) may be considered for severe chronic atopic dermatitis 3

Adjunctive Treatments

Infection Management

• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection, not for non-infected atopic dermatitis 3, 1
• Systemic antiviral agents should be used for eczema herpeticum 3

Symptom Management

• Antihistamines may be used for short-term, intermittent relief of sleep disturbance due to itch, but are not recommended for routine treatment of atopic dermatitis 1

Allergy Considerations

• Allergy testing should only be performed when there are specific concerns identified during history taking 3
• Food elimination diets based solely on allergy test results are not recommended 3
• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 3

Treatment Algorithm

1. Mild Atopic Dermatitis:

   • Emollients plus low-potency TCS or TCI 1

2. Moderate Atopic Dermatitis:

   • Emollients plus medium-potency TCS or TCI 1
   • Consider proactive maintenance therapy 1

3. Severe or Refractory Atopic Dermatitis:

   • Add phototherapy (preferably narrowband UVB) 1

4. Very Severe or Phototherapy Failure:

   • Consider systemic therapy with dupilumab, tralokinumab, or JAK inhibitors 1

Common Pitfalls to Avoid

• Relying on antihistamines as primary treatment for itch 3
• Using systemic antibiotics without evidence of infection 3
• Recommending elimination diets based solely on allergy testing 3
• Discontinuing topical therapy completely after resolution of acute flares, rather than transitioning to maintenance therapy 3
• Neglecting the importance of patient education in disease management 3

Interventions Not Recommended

• Systemic antibiotics for non-infected atopic dermatitis 3
• Probiotics/prebiotics for established atopic dermatitis 3
• Dietary supplements including fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12, and B6 3
• Sublingual or injection immunotherapy 3
• Alternative therapies such as Chinese herbal therapy, massage therapy, aromatherapy, naturopathy, hypnotherapy, acupressure, or autologous blood injections 3