Management of Atopic Dermatitis
Begin with daily ceramide-containing moisturizers applied immediately after bathing, combined with topical corticosteroids as first-line therapy for active lesions, then transition to proactive maintenance therapy with either topical corticosteroids (1-2× weekly) or topical calcineurin inhibitors (2-3× weekly) to previously affected areas once disease stabilizes. 1, 2, 3
Initial Management Algorithm
Step 1: Skin Barrier Restoration (All Patients)
- Apply ceramide-containing moisturizers immediately after bathing to repair barrier dysfunction 2
- Use at least 250 grams per week in adults 4
- Replace regular soaps with dispersible cream soap substitutes that don't strip natural lipids 5
- Avoid products containing fragrances and preservatives which act as irritants 2, 5
Step 2: Active Disease Treatment
- Topical corticosteroids are first-line therapy when nonpharmacologic interventions fail 1
- Select potency based on location: use lower potency on face/intertriginous areas to avoid skin atrophy 1, 5
- Topical calcineurin inhibitors (pimecrolimus, tacrolimus) are effective steroid-sparing agents for acute and maintenance therapy 1, 6
- Apply topical calcineurin inhibitors twice daily until symptoms resolve, but stop if no improvement after 6 weeks 6
- For sensitive areas like the face, topical calcineurin inhibitors should be considered over potent corticosteroids 7
Step 3: Transition to Maintenance Therapy (Critical Step Often Missed)
- After disease stabilization, continue topical corticosteroids 1-2× per week OR topical calcineurin inhibitors 2-3× per week to previously involved skin to prevent flares 1, 2, 3
- This proactive maintenance approach is strongly recommended but frequently overlooked 3, 5
- Continue daily moisturizers indefinitely 2, 5
Treatment Escalation for Inadequate Response
Moderate-to-Severe Disease Not Controlled by Topicals
- Phototherapy (narrowband UVB preferred) is recommended for patients failing optimized topical regimens 1, 2
- Narrowband UVB has the most favorable efficacy and safety profile 2
Severe or Refractory Disease
Biologics (strongest recommendations):
- Dupilumab and tralokinumab target Th2 inflammatory pathways with strong evidence 2, 4
- Dupilumab is particularly beneficial for patients with concurrent sinusitis or other atopic conditions 2
JAK Inhibitors (strong recommendations):
Traditional Immunosuppressants (conditional recommendations):
- Cyclosporine (1-4 mg/kg/day), azathioprine, methotrexate, or mycophenolate may be considered 1, 3
- Reserve these for patients where biologics/JAK inhibitors are not accessible or appropriate 1
Adjunctive Therapies for Specific Scenarios
Infection-Prone Patients
- Bleach baths (0.005% sodium hypochlorite) twice weekly with intranasal mupirocin for patients prone to skin infections 1
- Systemic antibiotics only when clinical evidence of bacterial infection exists 1, 3, 5
- Systemic antivirals for eczema herpeticum 3, 5
Sleep Disturbance from Pruritus
- Short-term sedating antihistamines may help with sleep disruption 1
- Non-sedating antihistamines are NOT recommended for routine AD treatment in absence of urticaria 1, 5
Wet Wrap Therapy
- Consider wet wraps with topical corticosteroids for recalcitrant patients, but avoid overuse 1
Assessment of Associated Conditions
Screen for and discuss these common associations:
- Rhinitis/rhinoconjunctivitis, asthma, food allergy 1
- Sleep disturbance, depression, and other neuropsychiatric conditions 1
- Consider integrated multidisciplinary care when multiple associations present 1
Allergy Testing: When and How
Food allergy evaluation is indicated ONLY for:
- Children <5 years with moderate-to-severe AD that persists despite optimized treatment 2, 3, 5
- Reliable history of immediate reaction after food ingestion 2, 3, 5
Patch testing should be considered for:
- Persistent/recalcitrant disease despite appropriate treatment 2, 5
- Clinical findings suggesting allergic contact dermatitis 2, 5
Do NOT perform allergy testing without specific clinical concerns identified in history 3, 5
Patient Education Component
- Educational interventions ("eczema schools") significantly improve outcomes and should be incorporated into management 2, 3, 5
- These programs provide sustained benefit and are recommended adjuncts to conventional therapy 3, 5, 4
Critical Pitfalls to Avoid
Discontinuing therapy after flare resolution:
- Stopping all topical therapy after acute flares resolve leads to recurrence 3, 5
- Must transition to maintenance regimen, not complete cessation 3, 5
Inappropriate use of systemic corticosteroids:
- Systemic corticosteroids should be avoided for long-term management 1, 2
- Short courses can trigger atopic flares after discontinuation 1
- Reserve only for acute severe exacerbations as bridge therapy to other systemic treatments 1, 5
Misuse of antibiotics:
- Do not use systemic antibiotics without evidence of infection 1, 3, 5
- Topical antimicrobials are generally not recommended except bleach baths 1
Inappropriate dietary restrictions:
- Do not recommend elimination diets based solely on positive IgE testing 1, 3, 5
- Food allergy testing without supportive clinical history leads to unnecessary restrictions 1, 3, 5
Relying on antihistamines for itch control:
- Antihistamines are not effective as primary treatment for AD-related pruritus 3, 5
- Only sedating antihistamines may help with sleep disturbance 1
Undertreatment due to "steroid phobia":
- Guidelines emphasize avoiding undertreatment of AD 1
- Appropriate use of topical corticosteroids with transition to maintenance therapy is safe and effective 1, 2