What is the management approach for a patient with atopic dermatitis?

Management of Atopic Dermatitis

For atopic dermatitis, begin with emollients and topical corticosteroids as first-line therapy, escalating to topical calcineurin inhibitors for steroid-sparing maintenance, then phototherapy for refractory cases, and finally systemic agents—with dupilumab, tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) as strongly preferred options over traditional immunosuppressants. 1, 2

First-Line Management: Topical Therapy

Emollients and Skin Barrier Restoration

• Apply emollients liberally and frequently (ideally after bathing) to all patients regardless of disease severity—this is foundational therapy that reduces flares and improves skin barrier function 1, 2, 3
• Use soap-free cleansers and bath oils instead of traditional soaps, as soaps strip natural lipids and worsen xerosis 1, 3
• Bathing is beneficial for cleansing and hydrating when followed immediately by emollient application 1

Topical Corticosteroids (TCS)

• TCS are the first-line pharmacologic treatment when emollients alone are insufficient 2, 3, 4
• Use the least potent preparation that controls disease, applying no more than twice daily (many newer preparations require only once-daily application) 1
• Potency selection by body site: Use low-potency TCS for face/intertriginous areas; medium-potency for trunk/extremities in moderate disease; reserve very potent/potent preparations for thick, lichenified areas with limited duration 1, 2
• Common pitfall: Undertreatment due to corticosteroid phobia—address patient/caregiver fears directly by explaining the safety profile when used appropriately 5, 4

Topical Calcineurin Inhibitors (TCI)

• Tacrolimus and pimecrolimus are effective steroid-sparing agents for both acute treatment and maintenance, particularly valuable for sensitive sites like the face where TCS risks are higher 2, 3, 6
• Can be used in conjunction with TCS as part of first-line therapy 3

Proactive Maintenance Therapy

• After achieving disease control, continue applying TCS (1-2× weekly) or TCI (2-3× weekly) to previously involved skin to prevent flares—this is a strong recommendation for relapse prevention 1, 2

Second-Line Management: Phototherapy

• Phototherapy is indicated for moderate-to-severe AD refractory to optimized topical therapy 1, 2
• Narrowband UVB (312 nm) is the preferred modality due to superior efficacy, safety profile, and availability compared to PUVA or broadband UVB 1, 2
• Maintenance typically requires 1× weekly indefinitely for many patients after initial clearance 1
• Caution: Long-term risks include premature skin aging and potential malignancy, particularly with PUVA 1

Third-Line Management: Systemic Therapy

Strongly Recommended Agents (First-Line Systemic Options)

The 2024 American Academy of Dermatology guidelines make strong recommendations for the following agents as preferred systemic therapies: 1

Biologics

• Dupilumab (IL-4 receptor antagonist): FDA-approved for moderate-to-severe AD in patients ≥6 months old 1, 2, 7

  • Adult dosing: 600 mg loading dose (two 300 mg injections), then 300 mg every 2 weeks 7
  • Pediatric dosing varies by weight and age—see detailed weight-based algorithms in FDA labeling 7
  • Advantage: Long-term safety profile allows treatment without routine laboratory monitoring 4

• Tralokinumab: Strongly recommended for moderate-to-severe AD 1, 2

JAK Inhibitors

• Abrocitinib, baricitinib, and upadacitinib all receive strong recommendations for moderate-to-severe AD 1, 2

Conditionally Recommended Agents (Alternative Systemic Options)

The following traditional immunosuppressants receive conditional recommendations—use when preferred agents are unavailable or contraindicated: 1

• Cyclosporine: Effective for refractory AD; dosing 3-6 mg/kg/day 1

  • Monitor creatinine closely—if increases >25% above baseline, reduce dose by 1 mg/kg/day for 2-4 weeks; discontinue if remains elevated 1

• Azathioprine: Recommended for refractory disease; dosing 1-3 mg/kg/day 1

  • Consider TPMT enzyme testing to guide dosing 1

• Methotrexate: Recommended for refractory AD; dosing 7.5-25 mg/week with mandatory folate supplementation 1

  • Monitor liver enzymes—hold if >2× normal, reduce dose if >3× normal 1

• Mycophenolate mofetil: Conditional recommendation as variably effective alternative; dosing 1-4 mg/kg/day 1

Systemic Corticosteroids: Avoid

• Conditional recommendation AGAINST systemic corticosteroids for AD management 1
• Reserve exclusively for acute severe exacerbations as short-term bridge therapy to steroid-sparing systemic agents 1
• Should never be used for maintenance treatment 1

Adjunctive Therapies

Infection Management

• Treat overt bacterial infection with systemic antibiotics (flucloxacillin for S. aureus, phenoxymethylpenicillin for streptococci, erythromycin for penicillin allergy) 1
• Do NOT use antibiotics for non-infected AD—they are not indicated for routine management 2
• Eczema herpeticum requires oral acyclovir started early; use IV acyclovir for ill, febrile patients 1

Antihistamines

• Limited role: May provide short-term relief of sleep disturbance from pruritus due to sedative properties, but not recommended for routine AD treatment 1, 2
• Non-sedating antihistamines have minimal value in AD 1
• Only consider if comorbid urticaria or rhinoconjunctivitis exists 2

Educational Interventions

• Structured educational programs ("eczema schools") are strongly recommended as adjuncts to conventional therapy—they improve outcomes by teaching disease recognition, trigger avoidance, proper medication application, and moisturization techniques 1, 2
• Video interventions and nurse-led programs also beneficial 1

Allergy Testing and Dietary Interventions

• Do NOT perform routine allergy testing without clinical suspicion—testing independent of history is not recommended 1
• Consider patch testing in persistent/recalcitrant AD or when allergic contact dermatitis is suspected 1
• Food elimination diets based solely on testing are NOT recommended 1
• Exception: Children <5 years with moderate-to-severe AD should be evaluated for milk, egg, peanut, wheat, soy allergy if: (a) persistent despite optimized treatment OR (b) reliable history of immediate reaction after food ingestion 1

Environmental Modifications and Complementary Therapies

• Avoid irritants: Cotton clothing preferred over wool; avoid temperature extremes; keep nails short 1
• House dust mite reduction: Limited evidence for routine use of dust mite covers even in sensitized patients 1
• NOT recommended due to insufficient evidence: Probiotics/prebiotics, fish oils, evening primrose oil, borage oil, vitamin supplements (D, E, B12, B6), zinc, Chinese herbal therapy, massage therapy 1

Treatment Algorithm Summary

1. Mild AD: Emollients + low-potency TCS or TCI 2
2. Moderate AD: Emollients + medium-potency TCS or TCI + proactive maintenance therapy 2
3. Severe/refractory AD: Add narrowband UVB phototherapy 2
4. Very severe/phototherapy failure: Systemic therapy with dupilumab, tralokinumab, or JAK inhibitors as preferred first-line options 1, 2
5. Traditional immunosuppressants (cyclosporine, azathioprine, methotrexate, mycophenolate) reserved for when preferred agents unavailable 1