What are the latest guidelines for managing atopic diseases, including atopic dermatitis, asthma, and allergic rhinitis?

Latest Guidelines for Atopic Dermatitis Management

The foundation of atopic dermatitis management is daily ceramide-containing moisturizers applied immediately after bathing, combined with proactive maintenance therapy using topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously affected areas after disease stabilization to prevent flares. 1, 2, 3

Diagnosis and Assessment

• Diagnosis is clinical, based on characteristic pruritic inflammatory skin lesions with typical distribution patterns (flexural areas in older children/adults, face and extensor surfaces in infants) 1
• Assess for environmental and food allergies during history taking, but pursue testing only if specific clinical concerns are identified (urticaria, immediate reactions) 1, 2
• Allergy testing independent of clinical history is not recommended 1, 2, 3
• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 1, 2, 3

First-Line Treatment Algorithm

Mild-to-Moderate Disease

• Apply ceramide-containing moisturizers liberally immediately after bathing to repair skin barrier dysfunction 2, 3
• Use gentle, soap-free cleansers to avoid removing natural lipids 3
• Apply topical corticosteroids twice daily during active flares, selecting potency based on anatomic location (lower potency for face/intertriginous areas, higher potency for trunk/extremities) 3, 4
• After disease stabilization, continue topical corticosteroids 1-2× per week to previously involved skin to prevent flares 1, 2, 3
• Topical calcineurin inhibitors (pimecrolimus, tacrolimus) are steroid-sparing alternatives, particularly for sensitive areas 3, 5, 6
• After disease stabilization, apply topical calcineurin inhibitors 2-3× per week to previously affected areas 1, 2, 3

Moderate-to-Severe Disease

When optimized topical therapy fails:

1. Phototherapy (narrowband UVB preferred) is the next step due to favorable efficacy and safety profile 1, 2, 3

2. Biologic therapy with dupilumab or tralokinumab receives strong recommendations as these target the IL-4/IL-13 pathway underlying atopic inflammation 2, 7

3. JAK inhibitors (abrocitinib, baricitinib, upadacitinib) receive strong recommendations for severe chronic disease 2, 3

4. Traditional systemic immunosuppressants (cyclosporine, azathioprine, methotrexate, mycophenolate mofetil) receive conditional recommendations when biologics/JAK inhibitors are not available 1, 2, 3

5. Systemic corticosteroids are not recommended for long-term management 2

Adjunctive Therapies

• Educational programs ("eczema schools") are strongly recommended as they significantly improve treatment outcomes and adherence 1, 2, 3
• Video interventions and nurse-led programs are useful adjuncts 1
• Wet wrap therapy may be beneficial during acute flares 3
• Bleach baths (twice weekly) may help patients prone to skin infections 3

Food Allergy Evaluation

Children under 5 years with moderate-to-severe atopic dermatitis should be considered for food allergy evaluation (milk, egg, peanut, wheat, soy) only if: 1, 2, 3

• Persistent disease despite optimized treatment, OR
• Reliable history of immediate reaction after specific food ingestion

Food elimination diets based solely on allergy test results are not recommended 1, 2, 3

Antimicrobials and Antihistamines

• Systemic antibiotics are not recommended for non-infected atopic dermatitis 1, 2, 3
• Systemic antibiotics are appropriate only when clinical evidence of bacterial infection exists 1, 2, 3
• Systemic antiviral agents should be used for eczema herpeticum 1
• Oral antihistamines are not recommended as primary treatment for atopic dermatitis itch 1, 2, 3, 6
• Short-term sedating antihistamines may help with sleep disturbance secondary to itch, but should not substitute for topical anti-inflammatory therapy 1, 3

Critical Pitfalls to Avoid

• Discontinuing topical anti-inflammatory therapy completely after flare resolution instead of transitioning to proactive maintenance therapy 2, 3
• Relying on oral antihistamines as primary itch control rather than addressing underlying inflammation 1, 2, 3
• Using systemic antibiotics without documented infection 1, 2, 3
• Recommending elimination diets based solely on positive allergy tests without clinical correlation 1, 2, 3
• Using products with fragrances and preservatives that may act as irritants 2
• Neglecting patient education, which significantly improves adherence and outcomes 1, 2, 3

Special Considerations

For patients with both atopic dermatitis and chronic rhinosinusitis, dupilumab is particularly beneficial as it targets the Th2 inflammatory pathway underlying both conditions 2, 7