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

Atopic Dermatitis Treatment

Stepwise Treatment Algorithm

All patients with atopic dermatitis should start with liberal emollient application and soap-free cleansers, progressing to topical corticosteroids for active disease, then phototherapy if topical therapy fails, and finally systemic biologics or JAK inhibitors for moderate-to-severe refractory disease. 1, 2, 3

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Foundation: Skin Barrier Management (All Patients)

• Apply emollients liberally and frequently throughout the day, immediately after bathing while skin is still damp to maximize moisture retention 2, 3, 4
• Replace all traditional soaps with soap-free cleansers or dispersable cream substitutes to prevent stripping natural lipids 3, 4
• Bathing is beneficial when followed immediately by emollient application 3

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First-Line Pharmacologic Treatment: Topical Anti-Inflammatory Therapy

Topical Corticosteroids (Primary First-Line)

Topical corticosteroids are the first-line pharmacologic treatment when emollients alone are insufficient. 2, 3, 5

• Face and intertriginous areas: Use only low-potency preparations to avoid skin atrophy 3, 4
• Trunk and extremities: Use medium-potency preparations for moderate disease 3
• Thick, lichenified areas: Reserve very potent/potent preparations for limited duration 3
• Apply once to twice daily to affected areas until flare resolves 4
• Use the least potent preparation that controls disease 3, 4

Topical Calcineurin Inhibitors (Steroid-Sparing Alternative)

• Tacrolimus and pimecrolimus are effective steroid-sparing agents for both acute and maintenance therapy 2
• Particularly useful for sensitive areas (face, eyelids, intertriginous zones) where corticosteroid side effects are concerning 4
• Can be used in conjunction with topical corticosteroids as first-line treatment 4
• Despite the FDA black box warning from 2005, no signal for cancer risk has emerged in clinical use 1

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Proactive Maintenance Therapy (Prevent Flares)

After achieving disease control, continue applying topical corticosteroids 1-2 times weekly OR topical calcineurin inhibitors 2-3 times weekly to previously affected skin to reduce subsequent flares. 1, 2, 4

This proactive approach represents a paradigm shift from purely reactive treatment and significantly lengthens time to relapse 4

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Second-Line Treatment: Phototherapy

Phototherapy is indicated for moderate-to-severe atopic dermatitis refractory to optimized topical therapy. 1, 2, 3

• Narrowband UVB is the preferred modality due to superior efficacy, safety profile, and availability compared to PUVA or broadband UVB 2, 3
• Maintenance typically requires once-weekly treatment indefinitely after initial clearance 3

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Third-Line Treatment: Systemic Therapy

Preferred Systemic Agents (Strong Recommendations)

For moderate-to-severe atopic dermatitis failing phototherapy or when phototherapy is not viable, the American Academy of Dermatology makes strong recommendations for dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib. 1

Biologics:

• Dupilumab: FDA-approved for patients ≥6 months old; dosing is 600 mg loading dose, then 300 mg every 2 weeks 3
• Tralokinumab: Strongly recommended for moderate-to-severe disease 1, 2, 3

JAK Inhibitors:

• Abrocitinib, baricitinib, and upadacitinib all receive strong recommendations 1, 2, 3

Conditional Recommendations (Alternative Systemic Agents)

The American Academy of Dermatology makes conditional recommendations in favor of azathioprine, cyclosporine, methotrexate, and mycophenolate 1

Systemic Corticosteroids

The American Academy of Dermatology makes a conditional recommendation AGAINST the use of systemic corticosteroids. 1

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Adjunctive Therapies During Flares

Infection Management

• Bacterial infection: Treat overt bacterial infection with systemic antibiotics (flucloxacillin for S. aureus, phenoxymethylpenicillin for streptococci, erythromycin for penicillin allergy) 3
• Do NOT use systemic antibiotics for non-infected atopic dermatitis 2
• Viral infection: Watch for eczema herpeticum, which requires prompt antiviral therapy 4

Antihistamines

• Sedating antihistamines may provide short-term benefit during severe flares primarily through sedative properties to improve sleep, not through direct antipruritic effects 4
• Non-sedating antihistamines have little to no value in atopic dermatitis management 4
• Antihistamines are not recommended for routine treatment unless the patient also has urticaria or rhinoconjunctivitis 2

Wet Wrap Therapy

• Consider wet wrap therapy and soak-and-seal techniques for intensive topical therapy 1

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Patient Education (Strongly Recommended)

Structured educational programs ("eczema schools") are strongly recommended as adjuncts to conventional therapy, as they improve outcomes by teaching disease recognition, trigger avoidance, proper medication application, and moisturization techniques. 1, 3

• Address topical steroid phobia through education, as fear of topical anti-inflammatory medications is the most prevalent barrier to adherence 1
• Video interventions and nurse-led programs may be useful adjuncts 1

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Allergy Testing and Dietary Interventions

When to Test:

• Do NOT perform routine allergy testing without clinical history suggesting specific allergies 3, 4
• Consider patch testing in persistent/recalcitrant disease or when allergic contact dermatitis is suspected 1, 3
• Children <5 years with moderate-to-severe atopic dermatitis should be evaluated for milk, egg, peanut, wheat, and soy allergy IF persistent despite optimized treatment OR with reliable history of immediate reaction after food ingestion 1, 3

Dietary Interventions:

• Food elimination diets based solely on allergy test results are NOT recommended 1, 3, 4
• If a patient has a true IgE-mediated allergy, practice avoidance to prevent serious health sequelae 1

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Before Initiating Systemic Therapy: Critical Assessment

The International Eczema Council recommends a systematic approach before systemic therapy 1:

• Consider alternate or concomitant diagnoses (contact dermatitis, cutaneous T-cell lymphoma, psoriasis, scabies, tinea) 1
• Optimize topical therapy and ensure adequate patient/caregiver education 1
• Treat coexistent infection 1
• Assess impact on quality of life 1
• Consider phototherapy before systemic agents 1
• Ensure adherence issues are addressed, as failure may be due to lack of adherence rather than treatment inefficacy 1

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Common Pitfalls to Avoid

• Never use potent topical corticosteroids on the face—this leads to skin atrophy and other complications 4
• Do not continue ineffective first-line treatment indefinitely; escalate therapy or refer to dermatology if no improvement occurs after appropriate trial 4
• Infants are particularly susceptible to topical corticosteroid side effects due to high body surface area-to-volume ratio—use only mild-potency preparations 4
• Do not implement food elimination diets without documented clinical reactions 4

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When to Refer to Dermatology

Refer when 4:

• Failure to respond to first-line treatment
• Diagnostic uncertainty exists
• Second-line treatments (phototherapy, systemic therapy) are being considered
• Disease significantly impacts quality of life