What is the management for atopic dermatitis?

Management of Atopic Dermatitis

The management of atopic dermatitis requires a structured approach beginning with daily skin care, topical anti-inflammatory treatments, and progressing to systemic therapies for more severe cases. 1, 2

First-Line Treatments

• Apply ceramide-containing moisturizers immediately after bathing to repair skin barrier dysfunction 2
• Use mild, fragrance-free cleansers and avoid potential irritants in skin care products 2
• For active lesions, apply topical corticosteroids (TCS) of appropriate potency based on location and severity 1, 2
  • Use lower potency TCS for face, neck, intertriginous areas
  • Use medium to high potency TCS for trunk and extremities
• Topical calcineurin inhibitors (TCIs) are appropriate alternatives, especially for sensitive areas like the face 1, 2
• After disease stabilization, implement maintenance therapy with TCS (1-2× per week) or TCIs (2-3× per week) to previously affected areas to prevent flares 1, 2

Moderate-to-Severe Disease Management

• Phototherapy (preferably narrowband UVB) should be considered for patients who fail to respond adequately to optimized topical regimens 2
• For patients with moderate-to-severe atopic dermatitis not adequately controlled with topical therapies, dupilumab is indicated for patients aged 6 months and older 3
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib) are recommended for moderate-to-severe disease 2
• Traditional immunosuppressants like cyclosporine (1-4 mg/kg/day), azathioprine, methotrexate, or mycophenolate may be considered for severe chronic atopic dermatitis 1, 2
• Systemic corticosteroids should be avoided for long-term management 2

Adjunctive Approaches

• Educational interventions ("eczema schools") significantly improve treatment outcomes and should be incorporated into management 1, 2
• Bleach baths and wet dressings may be helpful during flares 4
• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection 1, 2
• Systemic antiviral agents should be used for eczema herpeticum 1
• Patch testing should be considered for patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 1, 2

Allergy Considerations

• Allergy testing should only be performed when there are specific concerns identified during history taking 1, 2
• Food elimination diets based solely on allergy test results are not recommended 1, 2
• 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 2

Treatment Algorithm

1. Mild Disease:

   • Daily ceramide-containing moisturizers 2
   • Low-potency TCS or TCIs for active lesions 2
   • Transition to maintenance therapy after clearance 1, 5

2. Moderate Disease:

   • Medium-potency TCS for active lesions 2
   • Consider TCIs for sensitive areas 2
   • Maintenance therapy after clearance 1, 2
   • Consider phototherapy if inadequate response 2

3. Severe Disease:

   • High-potency TCS for acute flares 2
   • Consider dupilumab for patients aged 6 months and older with inadequate response to topical therapy 3
   • Consider JAK inhibitors or traditional immunosuppressants 2

Common Pitfalls to Avoid

• Relying on oral antihistamines as primary treatment for itch 1, 2
• Using systemic antibiotics without evidence of infection 1, 2
• Recommending elimination diets based solely on allergy testing results 1, 2
• Discontinuing topical therapy completely after resolution of acute flares, rather than transitioning to maintenance therapy 1, 2
• Using products with potential irritants such as fragrances and preservatives 2
• Using systemic corticosteroids for long-term management 2
• Neglecting the importance of patient education in disease management 1, 2