What is the recommended treatment for atopic dermatitis?

Treatment of Atopic Dermatitis

For adults with atopic dermatitis, begin with topical corticosteroids and moisturizers as first-line therapy; for moderate-to-severe disease refractory to topicals, use dupilumab, tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) as these have the strongest evidence for efficacy and safety. 1

Stepwise Treatment Algorithm

Step 1: Foundation Therapy (All Patients)

• Apply moisturizers liberally and frequently to maintain skin barrier function 1
• Use soap-free cleansers with daily bathing 1, 2
• Implement trigger avoidance based on individual patient history 3

Step 2: First-Line Pharmacologic Treatment

Topical Corticosteroids (TCS):

• Primary treatment for active flares with potency selection based on body site 1, 2
• Continue maintenance therapy (1-2× weekly) on previously affected areas after stabilization to prevent flares 3
• Avoid prolonged use on face/sensitive areas due to atrophy risk 4

Topical Calcineurin Inhibitors (TCIs):

• Pimecrolimus 1% or tacrolimus are strongly recommended as first-line agents 1
• Preferred for facial/sensitive skin areas where corticosteroid atrophy is concerning 5, 4
• Pimecrolimus is FDA-approved as second-line therapy for patients ≥2 years who failed other topicals 5
• Tacrolimus shows superior efficacy compared to hydrocortisone 1% (56% vs 27% EASI score reduction) 6

Topical JAK Inhibitors and PDE-4 Inhibitors:

• Strongly recommended as first-line options 1
• Crisaborole (PDE-4 inhibitor) is effective but cost may limit use 2

Step 3: Second-Line Therapy for Refractory Disease

When topical therapy fails or disease significantly impacts quality of life:

Biologic Agents (Strong Recommendations):

• Dupilumab - strongest recommendation for moderate-to-severe AD 1
• Tralokinumab - strong recommendation 1

Oral JAK Inhibitors (Strong Recommendations):

• Abrocitinib 1
• Baricitinib 1
• Upadacitinib 1, 7

Phototherapy (Conditional Recommendation):

• Narrowband UVB, broadband UVB, or UVA for extensive disease 1
• Safe and effective when first-line treatments inadequate 2
• Many patients require 1×/week maintenance indefinitely 1

Traditional Immunosuppressants (Conditional Recommendations):

• Cyclosporine (1-4 mg/kg/day): Effective for refractory AD; monitor creatinine (reduce dose if >25% above baseline) 1, 3
• Azathioprine (1-3 mg/kg/day): Dosing may be guided by TPMT enzyme activity 1
• Methotrexate (7.5-25 mg/week): Requires folate supplementation; monitor liver enzymes 1
• Mycophenolate mofetil: Variably effective alternative 1

Step 4: Adjunctive Therapies

During Active Flares:

• Bleach baths may provide benefit 7
• Wet wrap therapy conditionally recommended 1

For Secondary Bacterial Infection:

• Systemic antibiotics only when clinical evidence of infection exists (not for non-infected AD) 1, 3

For Eczema Herpeticum:

• Systemic antiviral agents are mandatory 1, 3

Patient Education:

• Educational interventions and "eczema schools" are beneficial adjuncts 3

Critical Pitfalls to Avoid

Do NOT use:

• Systemic corticosteroids except for acute severe exacerbations as short-term bridge therapy only 1
• Oral antihistamines as routine treatment - insufficient evidence for efficacy; sedating antihistamines only for sleep loss from itch 1, 2
• Systemic antibiotics without documented infection 1, 3
• Dietary elimination based solely on allergy testing 3
• Probiotics, dietary supplements (fish oil, evening primrose oil, vitamins), or alternative therapies - lack evidence 3

Allergy Testing Guidance:

• Only perform when specific concerns identified in history 3
• Consider food allergy evaluation only in children <5 years with moderate-to-severe AD that persists despite optimized treatment or with reliable history of immediate reaction 3
• Patch testing for persistent/recalcitrant disease or suspected allergic contact dermatitis 3

Key Monitoring Parameters

For Traditional Immunosuppressants:

• Cyclosporine: Baseline and ongoing creatinine, blood pressure, magnesium, potassium 1
• Azathioprine: CBC, liver enzymes, consider TPMT testing 1
• Methotrexate: Liver enzymes, CBC; liver biopsy at 3.5-4.0g cumulative dose 1
• All agents: Baseline TB testing 1