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

Treatment Options for Atopic Dermatitis

All patients with atopic dermatitis should begin with liberal emollient use and topical corticosteroids as first-line therapy, escalating to topical calcineurin inhibitors, phototherapy, and ultimately systemic agents (dupilumab, tralokinumab, or JAK inhibitors) based on disease severity and treatment response. 1, 2

Foundation: Emollients and Basic Skin Care

• Apply emollients liberally and frequently throughout the day to maintain skin hydration and restore barrier function 1, 2
• Use soap-free cleansers and bath oils for all patients 3
• Emollients provide both short- and long-term steroid-sparing effects in mild to moderate disease 2

First-Line Pharmacologic Treatment: Topical Corticosteroids

Potency selection depends on anatomic location:

• Low-potency topical corticosteroids (1% hydrocortisone, class VI-VII) for face, neck, genitals, and body folds due to increased atrophy risk in thin-skinned areas 2
• Medium-potency topical corticosteroids (fluticasone, mometasone, class IV-V) for trunk and extremities 2
• For severe flares requiring intensive therapy: medium-to-high potency topical corticosteroids once or twice daily for 1-4 weeks, followed by a taper 4

Proactive Maintenance Strategy

• Apply low-to-medium potency topical corticosteroids twice weekly to previously affected areas for up to 16 weeks to prevent relapses 4, 2
• Alternatively, topical calcineurin inhibitors 2-3 times per week after disease stabilization reduces subsequent flares 4

Steroid-Sparing Agents: Topical Calcineurin Inhibitors

• Tacrolimus (0.03-0.1%) or pimecrolimus (1%) are effective for sensitive areas or when topical corticosteroids alone are insufficient 1, 2
• These agents are particularly useful for facial and intertriginous areas where long-term corticosteroid use poses greater risk 5
• Despite the FDA black box warning, no signal for cancer risk has emerged in clinical use 4

Critical Pitfall to Avoid

Never use systemic corticosteroids as they carry substantial risk of serious adverse events and frequently cause rebound flares upon discontinuation 1, 2

When to Escalate: Algorithm for Advanced Therapies

Step 1: Assess Disease Severity and Treatment Adequacy

Before advancing to systemic therapy, confirm the following criteria are met:

• Moderate-to-severe atopic dermatitis defined by lesional severity/extent and/or significant impact on quality of life 4
• Adequate patient education provided, including trigger avoidance, adherence counseling, optimization of topical therapy, and addressing topical steroid phobia 4
• Intensive topical therapy trial completed: medium-to-high potency topical anti-inflammatory therapy for 1-4 weeks followed by proactive maintenance 4
• Consider wet wrap therapy and soak-and-seal techniques during intensive phase 4

Step 2: Rule Out Alternative Diagnoses

In patients with severe or refractory disease, consider:

• Contact dermatitis (atypical or localized distribution) 4
• Cutaneous T-cell lymphoma in adults (lack of classic eczematous changes like oozing/crusting) 4
• Patch testing should be performed in patients with persistent/recalcitrant disease 4

Step 3: Phototherapy (Second-Line)

• Narrowband UVB is the preferred phototherapy modality due to efficacy, safety profile, and availability 1
• Phototherapy is strongly recommended for recalcitrant atopic dermatitis after failure of first-line topical treatments 4, 1

Step 4: Systemic Therapy (Third-Line)

The American Academy of Dermatology makes strong recommendations for the following agents:

Preferred Systemic Agents (Strong Recommendations):

• Dupilumab (FDA-approved for patients ≥6 months with moderate-to-severe disease) 4, 1
• Tralokinumab for moderate-to-severe disease 4, 1
• JAK inhibitors: abrocitinib, baricitinib, or upadacitinib for moderate-to-severe disease 4, 1

Alternative Systemic Agents (Conditional Recommendations):

The American Academy of Dermatology makes conditional recommendations in favor of:

• Azathioprine 4
• Cyclosporine 4
• Methotrexate 4
• Mycophenolate 4

Selection among systemic agents depends on childbearing capacity, comorbidities (renal dysfunction, diabetes, alcohol abuse), age, and patient preferences (injection vs tablets) 4

Adjunctive Treatments

Infection Management

• Systemic antibiotics only when clinical evidence of bacterial infection exists, not for non-infected atopic dermatitis 1
• Consider dilute bleach baths to reduce Staphylococcus aureus colonization and minimize flare recurrence 6, 3

Pruritus Management

• Sedating antihistamines may be used for short-term, intermittent relief of sleep disturbance due to itch 1
• Antihistamines are not recommended for routine treatment unless the patient also has urticaria or rhinoconjunctivitis 1
• Non-sedating antihistamines do not reduce pruritus in atopic dermatitis 5

Allergy Testing

• Allergy testing should be based on clinical history, not performed routinely 4
• Children <5 years with moderate-to-severe disease should be considered for food allergy evaluation (milk, egg, peanut, wheat, soy) if disease persists despite optimized treatment or if there is reliable history of immediate reaction 4
• Food elimination diets based solely on test results are not recommended 4

Educational Interventions

• Structured educational programs ("eczema schools") are recommended as adjunct to conventional therapy 4
• Video interventions and nurse-led programs may be useful adjuncts 4

Treatments NOT Recommended

• Probiotics/prebiotics for established atopic dermatitis (inconsistent evidence) 4
• Fish oils, evening primrose oil, borage oil, multivitamin supplements (inconsistent to no evidence) 4
• Routine oral antihistamines for itch control (ineffective) 5