What is the drug of choice for treating dermatitis?

Drug of Choice for Dermatitis

First-Line Treatment Depends on Dermatitis Type

For contact dermatitis, topical corticosteroids are the drug of choice, while for atopic dermatitis, the choice depends on disease severity—topical corticosteroids remain first-line for mild-to-moderate disease, but dupilumab or JAK inhibitors are preferred for moderate-to-severe disease requiring systemic therapy. 1

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Contact Dermatitis

Primary Treatment

• Topical corticosteroids are the first-line pharmacologic treatment for established contact dermatitis due to their anti-inflammatory, antipruritic, and vasoconstrictive actions 2, 3
• Potency selection should be based on severity and anatomic location—use lower potency steroids for face, neck, and skin folds to avoid skin atrophy 3
• Mid-potency topical corticosteroids applied twice daily are appropriate for mild-to-moderate cases 3

Critical Non-Pharmacologic Component

• Identification and avoidance of the causative allergen or irritant is essential and must precede or accompany topical corticosteroid therapy 2, 3
• Replace soaps and detergents with emollients to restore the skin barrier 2, 3

Important Pitfall

• Antibiotics are NOT indicated for uncomplicated contact dermatitis as it is not an infectious condition 2
• Topical antibiotics (neomycin, bacitracin) are common allergens themselves and can worsen the condition 2

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Atopic Dermatitis

Mild-to-Moderate Disease

Topical corticosteroids are the first-line drug treatment for atopic dermatitis flares 1, 4

Alternative First-Line Options:

• Tacrolimus 0.03% or 0.1% ointment is strongly recommended for adults with atopic dermatitis 1
• Pimecrolimus 1% cream is strongly recommended for adults with mild-to-moderate atopic dermatitis 1, 5
• Ruxolitinib cream (JAK inhibitor) is strongly recommended for mild-to-moderate disease 1
• Crisaborole ointment (PDE-4 inhibitor) is strongly recommended for mild-to-moderate disease 1

Key Considerations:

• Tacrolimus is more effective than pimecrolimus—patients treated with tacrolimus are almost twice as likely to improve compared to pimecrolimus 6
• Topical calcineurin inhibitors (tacrolimus, pimecrolimus) are particularly useful for sensitive areas like the face where potent corticosteroids risk causing atrophy 1, 7
• Pimecrolimus is FDA-approved only as second-line therapy for patients who have failed other topical treatments or when those treatments are not advisable 5

Moderate-to-Severe Disease Requiring Systemic Therapy

Dupilumab and tralokinumab (IL-4/IL-13 inhibitors) are the preferred systemic agents based on high-certainty evidence for efficacy and favorable safety profile 1

Key Advantages:

• No laboratory monitoring required before initiation or during treatment 1
• Conjunctivitis is the most common adverse event but is usually self-limited and managed with artificial tears 1

Alternative Systemic Options (in descending order of preference):

JAK Inhibitors (Oral):

• Highly effective with rapid onset for moderate-to-severe atopic dermatitis 1
• Require careful patient selection due to boxed warnings regarding cardiovascular events, malignancies, and VTE risk 1
• Appropriate laboratory and clinical monitoring is mandatory 1

Cyclosporine:

• Effective at initial doses of 3-5 mg/kg/day 1
• Limited to 1 year of use due to toxicity concerns 1
• Not FDA-approved for atopic dermatitis in the US (approved in EU) but approved for psoriasis 1
• Requires monitoring for renal toxicity and drug interactions 1

Mycophenolate mofetil/mycophenolic acid:

• Can be used as systemic therapy 1
• Note that 360 mg mycophenolic acid equals 500 mg mycophenolate mofetil 1

Maintenance Therapy

• Intermittent use of medium-potency topical corticosteroids (twice weekly) is strongly recommended to reduce disease flares and relapse 1

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Common Pitfalls to Avoid

What NOT to Use:

• Oral antihistamines are NOT recommended for atopic dermatitis as they do not reduce pruritus effectively 1, 4
• Topical antimicrobials are conditionally recommended AGAINST for routine atopic dermatitis management 1
• Topical antihistamines are conditionally recommended AGAINST 1
• Systemic antibiotics should be reserved exclusively for clinically manifest bacterial infections, not for colonization or uninfected dermatitis 1

Critical Safety Considerations:

• When prescribing cyclosporine, verify whether modified or non-modified formulation is dispensed as this alters bioavailability, efficacy, and safety 1
• For JAK inhibitors, baseline health risk factor assessment is essential before initiation 1

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Adjunctive Treatments

• Moisturizers are strongly recommended for all adults with atopic dermatitis 1
• Diluted bleach baths may be suggested for moderate-to-severe atopic dermatitis with clinical signs of secondary bacterial infection 1
• Wet dressings are conditionally recommended for moderate-to-severe atopic dermatitis during flares 1