What is the treatment for atopic dermatitis?

Treatment for Atopic Dermatitis

The first-line treatment for atopic dermatitis consists of liberal moisturizer use, topical corticosteroids for flares, and maintenance therapy with either topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to prevent disease recurrence. 1, 2, 3

Non-Pharmacological Management

• Daily application of ceramide-containing moisturizers is essential for skin barrier repair, especially immediately after bathing to lock in moisture 4
• Use dispersible cream as a soap substitute rather than regular soaps and detergents which remove natural lipids from the skin 3
• Avoid irritant clothing and opt for cotton clothing to minimize skin irritation 3
• Educational interventions such as training programs or "eczema schools" are recommended as adjuncts to conventional therapy 1, 3

Pharmacological Management

Acute Flare Treatment

• Topical corticosteroids are the first-line treatment for acute flares of atopic dermatitis 5

  • Select the least potent effective preparation to minimize side effects such as skin atrophy 3
  • Apply to affected areas until resolution of active inflammation

• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) can be used as first-line treatment in conjunction with topical corticosteroids 5

  • Particularly useful for sensitive areas like the face, neck, and intertriginous areas where corticosteroid use may cause adverse effects 6
  • Pimecrolimus cream 1% is indicated as second-line therapy for mild to moderate atopic dermatitis in patients 2 years and older 7
  • Tacrolimus 0.03% has been shown to be more efficacious than 1% hydrocortisone acetate in children with moderate to severe atopic dermatitis 8

Maintenance Therapy

• After disease stabilization, continue using either topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously involved skin to prevent flares 1, 2
• Daily moisturizer use should be continued indefinitely to maintain skin barrier function 4

Management of Specific Scenarios

Infected Atopic Dermatitis

• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection 2, 3
• Systemic antiviral agents are indicated for eczema herpeticum 2, 3

Moderate to Severe Disease

• For patients with inadequate response to topical therapy, consider:
  • Ultraviolet phototherapy as a safe and effective treatment 5
  • Systemic immunomodulatory agents when optimized topical regimens and/or phototherapy do not adequately control disease 3
  • Newer medications like dupilumab and upadacitinib for severe chronic atopic dermatitis 6

Allergy Evaluation and Dietary Considerations

• Allergy testing should only be performed when there are specific concerns identified during history taking 2, 3
• Food elimination diets based solely on food allergy test results are not recommended 1, 3
• 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 3

Common Pitfalls to Avoid

• Discontinuing moisturizer use after flare resolution can lead to recurrence 4, 3
• Using systemic antibiotics without evidence of infection is not recommended 2, 3
• Systemic steroids should be avoided if possible and reserved only for acute, severe exacerbations as a short-term bridge to steroid-sparing therapy 3
• Non-sedating antihistamines are not recommended for routine treatment of atopic dermatitis in the absence of urticaria or other atopic conditions 3
• Relying solely on moisturizers without addressing other aspects of atopic dermatitis management leads to inadequate treatment 4