What are the treatment options for dermatitis?

Treatment of Dermatitis

For dermatitis (atopic dermatitis), initiate treatment with liberal emollients combined with topical corticosteroids as first-line therapy, selecting potency based on severity: low-potency for mild disease, medium-potency for moderate disease, and high-potency for severe flares, always transitioning to proactive maintenance therapy rather than stopping abruptly. 1, 2

First-Line Treatment Approach

Emollients: The Essential Foundation

• Moisturizers are mandatory, not optional—apply liberally at least twice daily, particularly after bathing, to restore skin barrier function and reduce water loss 1, 2
• Use alcohol-free formulations containing 5-10% urea for optimal barrier repair 3
• Apply emollients to provide a surface lipid film that prevents evaporative water loss 3
• Continue daily emollient use indefinitely, even during maintenance phases 3

Topical Corticosteroids: First-Line Pharmacologic Therapy

• Topical corticosteroids (TCS) are the cornerstone of acute management when nonpharmacologic interventions (emollients alone) are insufficient 1, 2
• Apply twice daily to affected areas during acute flares for 1-4 weeks 1, 3
• Select potency based on severity and anatomical location:
  • Mild disease: Low-potency TCS 2, 3
  • Moderate disease: Medium-potency TCS 1, 2
  • Severe flares: High to very high-potency TCS (e.g., clobetasol propionate 0.05%), which achieves clear/almost clear status in 67.2% of patients within 2 weeks 3, 4
• Apply to clean, slightly damp skin for optimal absorption, then wait 15-30 minutes before applying emollients 4
• Avoid prolonged use of high-potency corticosteroids on thin skin areas (face, intertriginous areas) due to atrophy risk 4, 5

Topical Calcineurin Inhibitors: Steroid-Sparing Agents

• Tacrolimus and pimecrolimus are effective steroid-sparing agents for both acute and maintenance therapy 1, 2
• Use as second-line therapy when corticosteroids have failed or are not advisable (e.g., facial involvement, concern for atrophy) 3, 5
• Apply 2-3 times per week after disease stabilization for maintenance 3
• Common initial adverse effect: Burning sensation or stinging during first few days of application, which typically improves as lesions resolve 5
• Pimecrolimus 1% cream demonstrated 35% of patients achieving clear or almost clear status at 6 weeks versus 18% with vehicle 5
• Do not use in patients with Netherton's Syndrome or conditions with increased systemic absorption potential 5

Proactive Maintenance Therapy: Critical for Preventing Relapse

• After achieving control (typically 2-4 weeks), transition to proactive maintenance rather than stopping treatment abruptly 1, 3
• Apply medium-potency TCS twice weekly (e.g., weekend therapy) to previously affected areas for 16-20 weeks 3, 4
• This approach reduces relapse risk by 3.5-fold compared to stopping steroids entirely, with 87.1% remaining flare-free versus 65.8% with emollient alone 4
• Twice-weekly maintenance shows only 1% incidence of skin thinning in trials up to 52 weeks 4
• Continue daily emollient use indefinitely during maintenance 3, 4

Newer Topical Agents

Topical JAK Inhibitors

• Strongly recommended for atopic dermatitis based on recent evidence 1, 2
• Represent a newer class of topical anti-inflammatory agents with efficacy comparable to or exceeding traditional therapies 1

Topical PDE-4 Inhibitors

• Strongly recommended as an additional topical option for atopic dermatitis 1, 2
• Provide steroid-free anti-inflammatory treatment 1

When to Escalate Beyond Topical Therapy

Phototherapy: Second-Line for Recalcitrant Disease

• Consider phototherapy only after failure of optimized topical therapy (appropriate-potency corticosteroids, adequate duration, consistent emollient use) 1, 2
• Narrowband UVB is preferred over other phototherapy modalities due to superior efficacy, safety profile, and availability 2
• Phototherapy should be considered before systemic immunomodulatory agents 1, 3

Systemic Therapies: For Moderate-to-Severe Refractory Disease

• Reserve systemic therapy for moderate-to-severe disease unresponsive to optimized topical management and/or phototherapy 1, 2

Preferred systemic agents (strongly recommended):

• Dupilumab: FDA-approved for moderate-to-severe atopic dermatitis in patients 6 months and older 2
• Tralokinumab: Strongly recommended for moderate-to-severe disease 2
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib): Strongly recommended for moderate-to-severe disease 2

Traditional immunosuppressants (conditional recommendations):

• Cyclosporine: 1-3 mg/kg/day initially, titrate to 3-6 mg/kg/day 3
• Methotrexate: 7.5-25 mg/week with mandatory folate supplementation 3
• Azathioprine: 1-3 mg/kg/day (dosing may be guided by TPMT enzyme activity) 3

Adjunctive Therapies: Use Selectively

Antimicrobials

• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection, not for non-infected atopic dermatitis 2
• Before commencing treatment, bacterial or viral infections at treatment sites should be resolved 5
• Conditional recommendation against routine use of topical antimicrobials and antiseptics 1

Antihistamines

• Conditional recommendation against routine use for atopic dermatitis unless the patient also has urticaria or rhinoconjunctivitis 1, 2
• May be used for short-term, intermittent relief of sleep disturbance due to itch 2
• Oral antihistamines do not reduce pruritus in atopic dermatitis 6

Bathing and Wet Wrap Therapy

• Conditional recommendation for bathing practices and wet wrap therapy 1
• Use soap-free cleansers for daily bathing 6
• Wet wrap therapy may be considered for severe flares 4

Critical Pitfalls to Avoid

• Undertreatment is common: Use appropriate potency and adequate duration based on severity rather than defaulting to weak steroids 4
• Failure to implement maintenance therapy leads to rapid relapse—do not stop corticosteroids abruptly after clearing 3, 4
• Neglecting emollients significantly compromises outcomes—these are essential, not optional 3, 4
• Using high-potency steroids long-term on thin skin (face, flexures) risks atrophy 4, 5
• Topical calcineurin inhibitors may increase risk of skin infections including eczema herpeticum, herpes simplex, and varicella zoster—monitor for worsening infections 5
• Patients developing lymphadenopathy while using topical calcineurin inhibitors should have etiology investigated; discontinue if no clear infectious cause is identified 5

Special Considerations

Allergen Management

• Assess for environmental and food allergies during history taking, as atopic dermatitis patients have increased rates 3
• Patch testing should be considered in patients with persistent/recalcitrant disease or findings consistent with allergic contact dermatitis 3
• Food elimination diets based solely on allergy test results are not recommended 3

Sun Exposure

• Patients should minimize or avoid natural or artificial sunlight exposure during treatment with topical calcineurin inhibitors, even when medication is not on the skin 5

Monitoring for Complications

• Monitor for skin infections: Patients are predisposed to superficial infections including eczema herpeticum (Kaposi's varicelliform eruption) 5
• Skin papillomas (warts) occurred in 1% of patients using pimecrolimus; consider discontinuation if warts worsen or don't respond to conventional therapy 5