What are the treatment options for a patient with atopic dermatitis?

Treatment Options for Atopic Dermatitis

Begin with daily emollients and moisturizers as foundational therapy, advance to topical corticosteroids for active lesions, and escalate to phototherapy or systemic agents (dupilumab, tralokinumab, or JAK inhibitors) only after optimizing topical therapy and patient education. 1, 2

Stepwise Treatment Algorithm

Step 1: Basic Skin Care (All Patients)

• Apply ceramide-containing moisturizers immediately after bathing to repair skin barrier dysfunction 2
• Use soap-free cleansers and avoid products with fragrances or preservatives that act as irritants 2
• Implement daily bathing followed by liberal emollient application 3
• Discuss and avoid specific trigger factors including detergents, sweat, saliva, aeroallergens, contact allergens, and psychological stress 4

Step 2: First-Line Pharmacologic Therapy

For mild disease:

• Low-potency topical corticosteroids (TCS) applied once or twice daily to active lesions 1
• Topical calcineurin inhibitors (tacrolimus or pimecrolimus) as steroid-sparing alternatives, particularly for sensitive areas like the face 1, 3

For moderate disease:

• Medium-potency TCS applied once or twice daily 1
• Consider proactive maintenance therapy: apply TCS 1-2 times per week or topical calcineurin inhibitors 2-3 times per week to previously affected areas after stabilization to prevent flares 2

For severe disease requiring intensive clearance:

• Medium-to-high potency TCS (class I-III in US, class III-IV in Europe) once or twice daily for 1-4 weeks, then taper application frequency 4
• Consider wet wrap therapy and soak-and-seal techniques during the intensive phase 4

Step 3: Address Common Barriers to Success

Before advancing therapy, ensure:

• Comprehensive patient education has been provided, specifically addressing topical steroid phobia and the safety profile of topical calcineurin inhibitors 4
• Adherence is optimized—complex topical regimens that are not feasible may justify moving to systemic therapy 4
• Consider structured educational interventions ("eczema schools") which significantly improve treatment outcomes 2
• Treat secondary bacterial infections with flucloxacillin for Staphylococcus aureus or phenoxymethylpenicillin for β-hemolytic streptococci 4
• Treat eczema herpeticum with oral acyclovir early; use intravenous acyclovir for ill, febrile patients 4

Critical pitfall: Do not use systemic antibiotics without clinical evidence of infection—they are not indicated for non-infected atopic dermatitis 1, 2

Step 4: Second-Line Therapy (Moderate-to-Severe Disease Unresponsive to Topicals)

Phototherapy:

• Narrowband UVB is the preferred phototherapy modality due to superior efficacy, safety profile, and availability 1, 2
• Indicated for recalcitrant atopic dermatitis after failure of optimized first-line topical treatments 1

Step 5: Systemic Therapy (Severe or Phototherapy-Refractory Disease)

Preferred systemic agents (in order of recommendation strength):

1. Dupilumab (FDA-approved for patients ≥6 months with moderate-to-severe disease)—particularly beneficial for patients with concurrent sinusitis as it targets the Th2 inflammatory pathway underlying both conditions 1, 2

2. Tralokinumab (strongly recommended for moderate-to-severe disease) 1, 2

3. JAK inhibitors (abrocitinib, baricitinib, upadacitinib)—strongly recommended for moderate-to-severe disease 1, 2

Traditional immunosuppressants (conditional recommendations):

• Azathioprine, cyclosporine, methotrexate, or mycophenolate may be considered but carry greater risks 2

Critical contraindication: Systemic corticosteroids are NOT recommended for long-term management despite their limited role in occasional severe flares 4, 2

Decision Points for Systemic Therapy

Advance to systemic therapy when:

• Moderate-to-severe disease is defined by lesional severity/extent AND/OR significant impact on quality of life (social, emotional, school/professional functioning) 4
• Intensive topical therapy (medium-to-high potency TCS for 1-4 weeks) has been given an adequate trial 4
• Patient education has been comprehensive and adherence barriers addressed 4
• Phototherapy is not viable or has failed 4

Choice of systemic agent depends on:

• Childbearing capacity
• Comorbidities (renal dysfunction, diabetes, alcohol abuse)
• Age
• Patient preferences (injection vs tablets) 4

Adjunctive Considerations

Antihistamines:

• Use only for short-term, intermittent relief of sleep disturbance due to itch 1
• NOT recommended for routine treatment unless concurrent urticaria or rhinoconjunctivitis exists 1
• Large doses may be required in children for nighttime use; avoid daytime use 4

Allergy evaluation:

• Patch testing should be considered for persistent/recalcitrant disease or suspected allergic contact dermatitis 2
• Children under 5 years with moderate-to-severe disease warrant food allergy evaluation ONLY if disease persists despite optimized treatment or immediate reactions occur after food ingestion 2
• Do not perform allergy testing without specific concerns identified during history taking 2

Bleach baths:

• Consider dilute bleach baths to reduce Staphylococcus aureus colonization and minimize risk for contamination of topical agents 5

Common Pitfalls to Avoid

• Do not rely on oral antihistamines as primary treatment for atopic dermatitis itch 2
• Do not recommend elimination diets based solely on allergy testing results 2
• Do not discontinue topical therapy completely after resolution of acute flares—implement proactive maintenance 2
• Do not use systemic corticosteroids for maintenance treatment until all other avenues have been explored 4