What is the recommended treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

For adults with atopic dermatitis, begin with topical corticosteroids and topical calcineurin inhibitors as first-line therapy, then escalate to dupilumab, tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) for moderate-to-severe disease refractory to topical treatments. 1

First-Line Topical Therapy

All patients require a foundation of moisturizers applied liberally with daily bathing using soap-free cleansers. 1, 2

Topical Anti-Inflammatory Agents (Strong Recommendations)

• Topical corticosteroids (TCS) are the primary treatment for active flares 1

  • Select potency based on disease severity and anatomic location 1
  • Avoid high-potency steroids on face, intertriginous areas, and thin skin 1
  • After stabilization, continue TCS 1-2 times weekly to previously involved skin to prevent flares 3

• Topical calcineurin inhibitors (TCIs) - tacrolimus and pimecrolimus - are strongly recommended 1

  • Particularly useful for sensitive areas like face and neck where corticosteroid atrophy is a concern 4, 5
  • Pimecrolimus is FDA-approved as second-line therapy for patients ≥2 years who failed other topical treatments 4
  • After stabilization, apply TCIs 2-3 times weekly to previously involved areas for maintenance 3
  • Main side effect is transient burning/pruritus in first few days 6

• Topical JAK inhibitors and PDE-4 inhibitors receive strong recommendations 1

What NOT to Use Topically

• Topical antimicrobials, antiseptics, and antihistamines receive conditional recommendations AGAINST routine use 1
• Systemic antibiotics should NOT be used for non-infected atopic dermatitis 1, 3
• Use systemic antibiotics ONLY when clinical evidence of bacterial superinfection exists 1, 3

Second-Line Systemic Therapy for Moderate-to-Severe Disease

When optimized topical regimens fail or disease significantly impacts physical, emotional, or social functioning, escalate to systemic therapy. 1

Preferred Systemic Agents (Strong Recommendations)

The 2024 AAD guidelines make strong recommendations for five agents: 1

• Dupilumab (IL-4/IL-13 inhibitor biologic)
• Tralokinumab (IL-13 inhibitor biologic)
• Abrocitinib (oral JAK1 inhibitor)
• Baricitinib (oral JAK1/JAK2 inhibitor)
• Upadacitinib (oral JAK1 inhibitor)

These represent the highest quality evidence for efficacy and safety in moderate-to-severe atopic dermatitis. 1

Alternative Systemic Agents (Conditional Recommendations)

When biologics or JAK inhibitors are not accessible or appropriate, consider traditional immunosuppressants: 1

• Cyclosporine 1-4 mg/kg/day - effective for refractory disease 1

  • Monitor creatinine; reduce dose if Cr increases >25% above baseline 1
  • Avoid long-term use due to nephrotoxicity risk 1

• Azathioprine 1-3 mg/kg/day 1

  • Consider TPMT enzyme testing before initiation 1
  • Monitor CBC and liver function 1

• Methotrexate 7.5-25 mg/week with folate supplementation 1

  • Monitor liver enzymes; discontinue if >5× normal 1
  • Avoid in patients at risk for hepatotoxicity 1

• Mycophenolate mofetil - variably effective alternative 1

Phototherapy (Conditional Recommendation)

Narrowband UVB phototherapy is conditionally recommended for extensive or refractory disease 1

• Effective for both acute and chronic atopic dermatitis 1
• Many patients require maintenance therapy 1×/week indefinitely 1

Systemic Corticosteroids (Conditional Recommendation AGAINST)

Avoid systemic steroids for atopic dermatitis 1

• Reserve exclusively for acute severe exacerbations 1
• Use only as short-term bridge to steroid-sparing therapy 1

Adjunctive Treatments

When to Use Systemic Antimicrobials

• Systemic antibiotics: Use ONLY with clinical evidence of bacterial infection (not prophylactically) 1, 3
• Systemic antivirals: Use for eczema herpeticum 1, 3

Antihistamines - Limited Role

Antihistamines are NOT recommended as routine treatment 1

• Sedating antihistamines may help with sleep loss from nocturnal itch, but should not replace topical therapy 1
• Non-sedating antihistamines are not recommended unless concurrent urticaria or allergic rhinitis 1

Allergy Evaluation - Selective Use Only

• Perform allergy testing ONLY when specific concerns identified in history 3
• Food elimination diets based solely on testing are NOT recommended 3
• Consider food allergy evaluation in children <5 years with moderate-to-severe disease ONLY if persistent despite optimized treatment or reliable history of immediate reaction 3

What Does NOT Work

Do not recommend: 3

• Probiotics/prebiotics
• Dietary supplements (fish oils, evening primrose oil, borage oil, vitamins D/E/B12/B6, zinc)
• Sublingual or injection immunotherapy
• Alternative therapies (Chinese herbs, massage, aromatherapy, acupressure, autologous blood injections)

Critical Pitfalls to Avoid

• Do not stop all topical therapy after flare resolution - transition to maintenance therapy with TCS 1-2×/week or TCI 2-3×/week 3
• Do not use antihistamines as primary itch treatment - they are ineffective for atopic dermatitis pruritus 1, 2
• Do not prescribe antibiotics without infection - no benefit in non-infected atopic dermatitis 1, 3
• Do not eliminate foods based on testing alone - requires clinical correlation 3
• Do not use systemic steroids as maintenance therapy - causes rebound flares and long-term complications 1

Treatment Algorithm Summary

1. All patients: Moisturizers + soap-free cleansers + patient education 1, 3
2. Mild-moderate disease: TCS and/or TCI for flares, then maintenance 1-3×/week 1, 3
3. Refractory to topicals: Consider phototherapy OR escalate to systemic therapy 1
4. Moderate-severe disease: Dupilumab, tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) 1
5. Alternative systemic options: Cyclosporine, azathioprine, methotrexate, mycophenolate 1
6. Superinfection: Add appropriate antimicrobials while continuing AD treatment 1, 3