What is the recommended treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

The recommended treatment for atopic dermatitis follows a stepwise approach, with dupilumab being the preferred first-line systemic agent for moderate-to-severe disease that doesn't respond to topical therapy. 1

First-Line Treatments

• Moisturizers/Emollients: Essential foundation therapy for both acute treatment and maintenance, applied after bathing 2
• Topical Corticosteroids (TCS): First-line pharmacologic therapy when nonpharmacologic interventions are insufficient 2
  • For maintenance after disease stabilization, use 1-2× per week to previously involved skin to prevent flares 1, 3
• Topical Calcineurin Inhibitors (TCI): Effective steroid-sparing agents for both acute and maintenance therapy 2
  • Pimecrolimus cream is indicated as second-line therapy for mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years and older 4
  • For maintenance after disease stabilization, use 2-3× per week to previously involved skin 1, 3

Treatment Algorithm Based on Severity

Mild Atopic Dermatitis

• Emollients plus low-potency TCS or TCI 2
• Proactive maintenance therapy with TCS (1-2× weekly) or TCI (2-3× weekly) after clearing 1

Moderate Atopic Dermatitis

• Emollients plus medium-potency TCS or TCI 2
• Consider proactive maintenance therapy 2
• Educational interventions as adjunctive therapy 1, 3

Severe or Refractory Atopic Dermatitis

• Add phototherapy (preferably narrowband UVB) if topical treatments fail 1, 2
• Narrowband UVB has excellent safety track record and is generally preferred over other modalities 2

Very Severe or Phototherapy Failure

• Systemic therapy is indicated when:
  • Optimized topical regimens and/or phototherapy do not adequately control disease 1
  • The skin disease has significant negative physical, emotional, or social impact 1
• Dupilumab is the preferred first-line systemic agent (all workgroup members favored it) 1
• Tralokinumab is the second biologic approved for AD, somewhat less effective than dupilumab at 16 weeks 1
• JAK inhibitors (abrocitinib, upadacitinib) are also options, with higher doses showing somewhat better efficacy than standard-dose dupilumab 1

Adjunctive Treatments

• Systemic antibiotics: Only for patients with clinical evidence of bacterial infections, not for non-infected atopic dermatitis 1, 3
• Systemic antiviral agents: Should be used for eczema herpeticum 3
• Antihistamines: May help with sleep disturbance due to itch but are not recommended for routine treatment 2, 5
• Bleach baths: Can be considered during flares 6

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 1, 3
• Discontinuing topical therapy completely after resolution of acute flares, rather than transitioning to maintenance therapy 1, 7
• Using systemic steroids, which should be avoided if possible and reserved only for acute, severe exacerbations and as a short-term bridge to steroid-sparing therapy 1

Special Considerations

• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 1, 3
• Allergy testing should only be performed when there are specific concerns identified during history taking 3
• Proactive therapy with twice-weekly application of topical anti-inflammatory medications significantly reduces the risk of relapse 8, 7
• For sensitive areas like the face, topical calcineurin inhibitors may be preferred over potent topical corticosteroids to avoid potential adverse effects 6, 9