What treatment options are available for an adult patient with a skin condition, possibly eczema or dermatitis, with no known allergies or sensitivities?

Treatment Options for Nyaderm (Eczema/Dermatitis)

For an adult patient with eczema or dermatitis, I strongly recommend starting with liberal daily moisturizer application combined with topical corticosteroids for flares, followed by topical calcineurin inhibitors (tacrolimus 0.1% or pimecrolimus 1%) as steroid-sparing maintenance therapy. 1

First-Line Treatment Approach

Daily Maintenance Therapy

• Apply moisturizers liberally and frequently to all affected areas, regardless of disease activity 1
• Use emollients immediately after bathing to damp skin to create a protective lipid barrier that prevents water loss 1, 2
• No specific moisturizer ingredient can be recommended over others based on current evidence, but fragrance-free formulations containing petrolatum or mineral oil are preferred 1
• Bathe with soap-free cleansers using tepid (not hot) water 1

Treatment of Active Flares

• Topical corticosteroids are the cornerstone of flare management 1
• For mild-to-moderate disease on the body: use medium-potency topical corticosteroids (e.g., mometasone furoate 0.1%) applied once or twice daily 1
• For facial involvement: use only low-potency corticosteroids (hydrocortisone 1%) for limited periods (2-4 weeks maximum) due to high risk of skin atrophy and telangiectasia 1, 2
• Apply topical corticosteroids to affected areas, then cover with moisturizer 1

Second-Line Topical Therapies

Topical Calcineurin Inhibitors (TCIs)

• For adults with atopic dermatitis, use tacrolimus 0.03% or 0.1% ointment as a strong recommendation based on high-certainty evidence 1
• For mild-to-moderate disease, pimecrolimus 1% cream is strongly recommended 1
• TCIs are particularly valuable for facial and intertriginous areas where corticosteroid side effects are most problematic 1
• Apply twice daily to affected areas 1

Newer Topical Agents

• Crisaborole ointment is strongly recommended for mild-to-moderate atopic dermatitis based on high-certainty evidence 1
• Ruxolitinib cream is strongly recommended for mild-to-moderate disease based on moderate-certainty evidence 1

Maintenance Strategy to Prevent Flares

Use medium-potency topical corticosteroids intermittently (2 times per week) on previously affected areas to reduce disease flares and relapse, even when skin appears clear 1. This proactive approach is strongly recommended based on high-certainty evidence 1.

When to Escalate Beyond Topical Therapy

Consider phototherapy or systemic agents when 1:

• Optimized topical regimens (emollients + topical anti-inflammatory therapies) fail to adequately control disease 1
• Disease significantly impacts work, school performance, or interpersonal relationships 1
• More than 10-20% body surface area is involved despite maximal topical therapy 1

Phototherapy Option

• Narrowband UVB phototherapy is conditionally recommended for adults with atopic dermatitis based on low-certainty evidence 1
• Most effective for moderate-to-severe disease when topical therapies are insufficient 1

Systemic Therapy Options (in order of preference)

For moderate-to-severe disease unresponsive to topicals and phototherapy 1:

1. Dupilumab is strongly recommended (moderate-certainty evidence) - monoclonal antibody targeting IL-4/IL-13, standard dosing 600mg initial then 300mg every 2 weeks 1
2. Tralokinumab is strongly recommended (moderate-certainty evidence) - monoclonal antibody targeting IL-13 1
3. Upadacitinib is recommended for refractory cases 1

Critical Pitfalls to Avoid

• Do not use topical antihistamines - they are conditionally recommended against due to lack of efficacy 1
• Do not routinely use topical antimicrobials unless there are clear signs of secondary bacterial infection (crusting, weeping, honey-colored exudate) 1
• Avoid prolonged continuous use of medium-to-high potency corticosteroids on the face beyond 2-4 weeks due to risk of skin atrophy, telangiectasia, and tachyphylaxis 1, 2
• Do not undertreat due to steroid phobia - appropriate potency for adequate duration followed by maintenance therapy is key 1
• Avoid hot water, harsh soaps, and alcohol-containing preparations that worsen barrier dysfunction 1, 2

Adjunctive Measures

• Identify and eliminate potential contact allergens (fragrances, preservatives like methylchlorothiazolinone, neomycin) 1
• Treat secondary bacterial infections with systemic antibiotics when present (not prophylactically) 1
• Consider dilute bleach baths (0.005% sodium hypochlorite) for moderate-to-severe disease with signs of secondary infection 1
• Minimize exposure to known triggers: overheating, stress, irritating fabrics 1

When to Refer to Dermatology

Refer when 1, 2:

• Diagnostic uncertainty or atypical presentation
• Failure to respond after 4-6 weeks of appropriate first-line therapy
• Need for systemic immunosuppressive therapy
• Suspected allergic contact dermatitis requiring patch testing
• Recurrent severe flares despite optimal maintenance therapy