Is a topical non-steroidal anti-inflammatory drug (NSAID) effective for treating atopic dermatitis?

Topical NSAIDs Are Not Recommended for Atopic Dermatitis

Topical NSAIDs have no established role in the treatment of atopic dermatitis and are not recommended by any major guidelines. The 2023 American Academy of Dermatology guidelines for managing atopic dermatitis with topical therapies do not include topical NSAIDs among recommended treatments 1.

Evidence-Based Treatment Hierarchy

The established topical treatments for atopic dermatitis, in order of evidence strength, are:

First-Line Treatments

• Topical corticosteroids remain the mainstay of treatment with high certainty evidence supporting their use for acute flares and maintenance therapy 1, 2
• Moisturizers and emollients are strongly recommended as foundational therapy for all patients 1, 3
• Topical calcineurin inhibitors (tacrolimus 0.03%/0.1% ointment and pimecrolimus 1% cream) have high certainty evidence for efficacy, particularly for sensitive areas like the face where corticosteroid side effects are concerning 1, 4

Second-Line Topical Options

• Crisaborole ointment (PDE-4 inhibitor) has high certainty evidence for mild-to-moderate disease 1
• Ruxolitinib cream (JAK inhibitor) has moderate certainty evidence for mild-to-moderate disease 1

Why NSAIDs Are Not Used

The pathophysiology of atopic dermatitis involves:

• Immune dysregulation with T-helper cell activation and cytokine release 5, 2
• Epidermal barrier dysfunction from gene mutations affecting skin structure 2
• Type 2 inflammatory pathways that are not primarily mediated by prostaglandins (the target of NSAIDs) 5

NSAIDs work by inhibiting cyclooxygenase enzymes to reduce prostaglandin synthesis, which is not the primary inflammatory mechanism in atopic dermatitis 5.

What Guidelines Explicitly Recommend Against

The AAD guidelines conditionally recommend against several topical agents that lack efficacy evidence 1:

• Topical antihistamines (conditional recommendation against, low certainty evidence) 1
• Topical antimicrobials for routine use (conditional recommendation against, low certainty evidence) 1
• Topical antiseptics except in specific circumstances with secondary infection (conditional recommendation against, very low certainty evidence) 1

Common Pitfall to Avoid

Do not confuse topical NSAIDs with topical corticosteroids—they are entirely different drug classes. Corticosteroids suppress multiple inflammatory pathways relevant to atopic dermatitis, while NSAIDs only inhibit prostaglandin synthesis 1, 5, 6.

Practical Treatment Algorithm

For a patient presenting with atopic dermatitis:

1. Start with emollients as soap substitutes and moisturizers applied liberally, especially after bathing 1, 3

2. Add topical corticosteroids matched to disease severity and anatomic location 1:

   • Face/neck: Low-potency (hydrocortisone 1%) 1, 6
   • Body/extremities: Medium-to-high potency (betamethasone valerate 0.1%) 1, 6
   • Apply once or twice daily until controlled, then consider maintenance therapy 2 times weekly 1

3. Consider topical calcineurin inhibitors for steroid-sensitive areas or when prolonged treatment is needed to avoid corticosteroid atrophy 1, 5

4. Reserve newer agents (crisaborole, ruxolitinib) for patients who fail or cannot tolerate first-line therapies 1