What are the treatment options for atopic dermatitis?

Treatment for Atopic Dermatitis

Apply moisturizers liberally after bathing as essential front-line therapy, then use topical corticosteroids twice daily during flares with potency selected by location, transitioning to maintenance therapy with topical corticosteroids (1-2× weekly) or topical calcineurin inhibitors (2-3× weekly) to prevent recurrence. 1, 2

Stepwise Treatment Algorithm

Mild Atopic Dermatitis

• Emollients plus low-potency topical corticosteroids or topical calcineurin inhibitors 2
• Use ceramide-containing moisturizers after bathing to hydrate skin and repair the barrier 1
• Apply gentle, soap-free cleansers to avoid removing natural lipids 1

Moderate Atopic Dermatitis

• Emollients plus medium-potency topical corticosteroids or topical calcineurin inhibitors 2
• Apply topical corticosteroids twice daily during flares until improvement, selecting potency based on anatomic location 1
• Consider topical calcineurin inhibitors (tacrolimus, pimecrolimus) as steroid-sparing agents, particularly for sensitive areas like face and neck 1, 3
• Transition to proactive maintenance therapy after clearing: topical corticosteroids 1-2× weekly OR topical calcineurin inhibitors 2-3× weekly to previously involved skin 4, 1

Severe or Refractory Atopic Dermatitis

• Add phototherapy (preferably narrowband UVB) after failure of optimized topical treatments 2
• Escalate treatment if inadequate response after 4-8 weeks of optimized topical therapy, extensive body surface area involvement, or significant quality of life impairment 1

Very Severe or Phototherapy Failure

• Systemic therapy with dupilumab (FDA-approved for ages 6 months and older), tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) as preferred options 2, 5
• Traditional immunosuppressants like cyclosporine (1-4 mg/kg/day) may be considered 4

Adjunctive Treatments

Infection Management

• Use antimicrobial bleach baths (0.005% sodium hypochlorite) twice weekly in patients prone to skin infections 1
• Systemic antibiotics ONLY when clinical evidence of bacterial infection exists—never for non-infected atopic dermatitis 4, 1, 2
• Systemic antiviral agents for eczema herpeticum 4

Symptom Management

• Short-term antihistamines may help with sleep disturbance due to pruritus but are NOT recommended for primary itch control 1
• Educational interventions such as training programs or "eczema schools" are beneficial adjuncts 4, 1

Special Populations

Children Under 5 Years

• Consider food allergy evaluation ONLY if persistent atopic dermatitis despite optimized treatment OR reliable history of immediate reaction after food ingestion 4, 1
• Do NOT perform food elimination diets based solely on allergy test results 4

Persistent/Recalcitrant Disease

• Consider patch testing for suspected allergic contact dermatitis 4, 1
• Allergy testing should only be performed when specific concerns identified during history taking 4

Critical Pitfalls to Avoid

• Never discontinue topical therapy completely after acute flare resolution—transition to maintenance therapy instead 4, 1
• Never rely on antihistamines as primary treatment for itch—address inflammation directly 1
• Never use systemic antibiotics without evidence of infection 4, 1, 2
• Never recommend elimination diets based solely on allergy testing 4
• Never neglect patient education—it is a beneficial adjunct to all conventional therapy 4, 1

Interventions NOT Recommended

• Probiotics/prebiotics for established atopic dermatitis 4
• Dietary supplements (fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12, B6) 4
• Sublingual or injection immunotherapy 4
• Alternative therapies (Chinese herbal therapy, massage therapy, aromatherapy, naturopathy, hypnotherapy, acupressure, autologous blood injections) 4