What is the first line management of adult atopic dermatitis?

First-Line Management of Adult Atopic Dermatitis

For adults with atopic dermatitis, begin with liberal moisturizer application combined with topical corticosteroids as the foundation of treatment, with topical calcineurin inhibitors (tacrolimus or pimecrolimus) serving as equally strong first-line alternatives, particularly for sensitive areas like the face, groin, and axillae. 1, 2

Core Foundation: Non-Pharmacologic Management

Moisturizers are non-negotiable baseline therapy for all patients regardless of disease severity. 1, 2

• Apply moisturizers liberally after every bath to hydrate skin and repair the compromised skin barrier 1, 2
• Use gentle, soap-free cleansers or dispersible creams as soap substitutes, as traditional soaps remove natural lipids from the skin surface 2
• Bathing is conditionally recommended for treatment and maintenance, though optimal frequency and duration cannot be specified based on current evidence 1

First-Line Pharmacologic Treatment

Topical Corticosteroids (TCS)

TCS are strongly recommended as first-line anti-inflammatory therapy with high certainty evidence. 1

• Apply medium-potency TCS to trunk and extremities twice daily during flares 2
• Use lower-potency TCS for sensitive areas (face, groin, axillae) due to increased absorption and atrophy risk 2
• Once improvement occurs, transition to intermittent maintenance therapy (twice weekly) to reduce disease flares and relapse 1
• Select TCS potency based on disease severity and anatomic location 1

Topical Calcineurin Inhibitors (TCIs)

TCIs are strongly recommended as first-line therapy with high certainty evidence, offering a safe anti-inflammatory option without corticosteroid-related adverse effects. 1

• Tacrolimus 0.1% ointment is strongly recommended for adults with atopic dermatitis 1, 3
• Pimecrolimus 1% cream is strongly recommended for adults with mild-to-moderate disease 1
• TCIs are particularly valuable for sensitive areas (face, groin, axillae) where skin atrophy from TCS is a concern 2, 4
• Tacrolimus 0.1% demonstrates superior efficacy compared to low-potency TCS, pimecrolimus 1%, and tacrolimus 0.03% 3
• The FDA black box warning regarding theoretical cancer risk is not supported by robust evidence after 15+ years of worldwide use 1, 4

Newer Topical Agents

Additional first-line options with strong recommendations include: 1, 2

• Crisaborole ointment (PDE-4 inhibitor) for mild-to-moderate AD 1
• Ruxolitinib cream (JAK inhibitor) for mild-to-moderate AD 1

Proactive Maintenance Strategy

Apply topical corticosteroids or topical calcineurin inhibitors twice weekly to previously affected areas to prevent flares, even when skin appears clear. 1, 2

• This proactive approach significantly reduces flare frequency and extends time between exacerbations 1, 4
• Pimecrolimus maintenance therapy increases mean days without requiring TCS for flares (152 vs 139 days) 1

Adjunctive Therapies for Acute Flares

• Wet wrap therapy is conditionally recommended for moderate-to-severe flares 1, 2
• Sedating antihistamines may provide short-term benefit during severe itching episodes, primarily through sedative properties rather than direct anti-pruritic effects 2

What NOT to Use

The following are conditionally recommended AGAINST based on low-quality evidence: 1, 2

• Topical antimicrobials (unless clinical signs of secondary bacterial infection are present) 1
• Topical antihistamines 1
• Topical antiseptics (exception: bleach baths may be considered for moderate-to-severe AD with clinical signs of secondary bacterial infection) 1

Common Pitfalls to Avoid

• Do not use systemic antibiotics routinely—reserve for clinically evident infection only 2
• Do not undertreat sensitive areas—use appropriate lower-potency TCS or switch to TCIs rather than avoiding treatment 2
• Do not discontinue maintenance therapy prematurely—continue twice-weekly proactive therapy to prevent relapses 1, 2
• Do not be deterred by the TCI black box warning—no strong evidence supports increased malignancy risk after extensive real-world use 1, 4

When to Escalate Beyond First-Line Therapy

Consider escalation to phototherapy or systemic therapies (dupilumab, tralokinumab, oral JAK inhibitors) if: 2

• Inadequate response after 4-8 weeks of optimized topical therapy 2
• Extensive body surface area is affected 2
• Quality of life is significantly impaired 2

Algorithmic Approach

1. Start all patients on liberal moisturizers + gentle bathing practices 1, 2
2. Add TCS (potency matched to location and severity) OR TCIs for active inflammation 1, 2
3. Apply twice daily during flares until improvement 2
4. Transition to twice-weekly proactive maintenance on previously affected areas 1, 2
5. Reassess at 4-8 weeks; if inadequate response, consider escalation 2