What is the recommended treatment for atopic dermatitis?

Recommended Treatment for Atopic Dermatitis

Start all patients with liberal moisturizer application after bathing and topical corticosteroids as first-line pharmacologic therapy, with topical calcineurin inhibitors, JAK inhibitors, or PDE-4 inhibitors as equally strong first-line alternatives, particularly for sensitive areas. 1, 2

Foundation: Non-Pharmacologic Management

Moisturizers and Bathing (Essential for All Patients)

• Apply moisturizers liberally after every bath to hydrate skin and repair the compromised barrier—this is non-negotiable baseline therapy regardless of disease severity. 1, 2
• Bathe with gentle, soap-free cleansers rather than traditional soaps that strip natural lipids from the skin surface. 2
• Use a dispersible cream as a soap substitute for cleansing. 2

Patient Education

• Educational interventions including training programs and "eczema schools" are beneficial adjuncts to conventional therapy. 3
• Identify and avoid known triggers such as irritants, extreme temperatures, and stress. 2

First-Line Pharmacologic Treatment

Topical Corticosteroids (TCS)

• TCS are the primary first-line pharmacologic treatment for atopic dermatitis flares. 1, 2, 4
• Apply twice daily during active flares until improvement is seen, then transition to maintenance therapy. 2
• Once-daily application is as effective as twice-daily or more frequent application. 5
• Potency selection depends on body location:
  • Medium-potency TCS for trunk and extremities (e.g., thighs). 2
  • Lower-potency TCS for groin, axillae, face, and other sensitive areas due to increased absorption and atrophy risk. 2

Topical Calcineurin Inhibitors (TCIs)

• Tacrolimus 0.1% ointment and pimecrolimus are strongly recommended as first-line options, particularly valuable for sensitive areas like the face, groin, and axillae where steroid-induced atrophy is a concern. 1, 2, 4
• TCIs can be used in conjunction with TCS as part of first-line treatment. 4
• Despite FDA boxed warnings about possible malignancy links, studies have not demonstrated a clear causal relationship. 5

Newer Topical Agents

• Topical JAK inhibitors (ruxolitinib) and topical PDE-4 inhibitors (crisaborole) are strongly recommended as first-line options. 1, 2
• These agents are effective but currently cost-prohibitive for most patients. 4

Maintenance Therapy to Prevent Flares

After achieving disease control, continue topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously involved skin—this proactive maintenance approach reduces relapse rates in patients with recurrent moderate to severe disease. 3, 2, 6

The proactive approach is evidence-based and immunologically founded, recognizing that normal-appearing, nonlesional skin in AD patients is not truly normal. 6 This strategy gives patients control over their disease and actively involves them in management. 6

Adjunctive Therapies During Flares

Wet Wrap Therapy

• Wet wrap therapy can be conditionally recommended for moderate-to-severe flares. 2

Antihistamines

• Sedating antihistamines may be useful as a short-term adjuvant during severe itching episodes, primarily for their sedative properties rather than direct antipruritic effects. 2, 7
• Oral antihistamines are not recommended as primary treatment because they do not effectively reduce pruritus. 4

Antimicrobials

• Use systemic antibiotics only for patients with clinical evidence of bacterial infections—they are not appropriate for non-infected atopic dermatitis or prevention of flares. 3, 4, 7
• Antistaphylococcal antibiotics are effective for treating secondary skin infections. 4
• Systemic antiviral agents should be used for eczema herpeticum. 3
• Topical antimicrobials, antiseptics, and antihistamines are conditionally recommended against for routine use. 1, 2

When to Escalate Beyond First-Line Therapy

If inadequate response after 4-8 weeks of optimized topical therapy, or if extensive body surface area is affected with significant quality of life impairment, escalate to phototherapy or systemic therapies. 2

Phototherapy (Second-Line)

• Phototherapy is recommended for both acute and chronic AD in children and adults after failure of topical measures. 1
• Multiple forms are beneficial including narrow-band UVB, broad-band UVB, UVA, and PUVA, though head-to-head comparisons are limited. 1
• Phototherapy is safe and effective for moderate to severe disease when first-line treatments are inadequate. 4

Systemic Therapies (Second-Line)

• Systemic immunomodulatory agents are indicated when optimized topical regimens (including emollients, topical anti-inflammatory therapies, and/or phototherapy) do not adequately control disease. 1
• Traditional immunosuppressants like cyclosporine (1-4 mg/kg/day) may be considered for severe chronic disease. 3, 7
• Newer biologics (dupilumab, tralokinumab) and oral JAK inhibitors (abrocitinib, baricitinib, upadacitinib) are strongly recommended for escalation. 2, 7
• Systemic corticosteroids like prednisone are FDA-approved for severe or incapacitating allergic conditions including atopic dermatitis. 8

Allergy Evaluation

• Perform allergy testing only when specific concerns are identified during history taking—not routinely. 3
• Do not recommend food elimination diets based solely on allergy test results. 3
• Consider food allergy evaluation only in children under 5 years with moderate to severe disease that persists despite optimized treatment, or with reliable history of immediate reaction after food ingestion. 3
• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis. 3

Interventions NOT Recommended

Avoid the following interventions as they lack evidence of benefit: 3

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

Critical Pitfalls to Avoid

• Do not rely on antihistamines as primary treatment for itch—they are ineffective for this purpose. 3, 4
• Do not use systemic antibiotics without evidence of infection. 3
• Do not discontinue topical therapy completely after resolution of acute flares—transition to maintenance therapy instead. 3, 2
• Do not recommend elimination diets based solely on allergy testing. 3
• Monitor for steroid-induced adverse effects: telangiectasia on cheeks increases with >20g applied to face over 6 months, and atrophy of antecubital/popliteal fossae occurs more frequently in males. 9