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

Management of Atopic Dermatitis

Foundation: Emollients and Skin Care

All patients with atopic dermatitis must apply emollients liberally and frequently throughout the day, as this is the cornerstone of management regardless of disease severity. 1, 2

• Apply emollients immediately after bathing while skin is still damp to maximize moisture retention and therapeutic benefit 1
• Replace all regular soaps with soap-free cleansers or dispersible cream substitutes, as traditional soaps strip natural lipids and worsen the underlying barrier dysfunction 3, 1, 2
• Bathing is beneficial for cleansing and hydration when followed immediately by emollient application 3, 2
• Avoid extremes of temperature, keep nails short, and avoid irritant clothing such as wool next to the skin; cotton clothing is preferred 3

First-Line Pharmacologic Treatment: Topical Corticosteroids

Topical corticosteroids are the mainstay of treatment for active atopic dermatitis and should be applied once daily to affected areas until the flare resolves. 3, 1, 2

Potency Selection by Anatomic Site

• Face and intertriginous areas: Use only mild-potency preparations to avoid skin atrophy and other complications 1, 2
• Trunk and extremities: Use mild-to-moderate potency preparations for most patients 1
• Thick, lichenified areas: Reserve potent or very potent preparations for limited duration only 2
• Use the least potent preparation required to control the eczema, stopping for short periods when possible 3, 1

Critical Pitfall to Avoid

Never use potent topical corticosteroids on the face—this is a critical error that leads to skin atrophy and other serious complications. 1

Alternative First-Line Option: Topical Calcineurin Inhibitors

• Topical calcineurin inhibitors (tacrolimus and pimecrolimus) can be used in conjunction with topical corticosteroids as first-line treatment 1, 4
• These agents are particularly valuable for sensitive areas (face, eyelids, intertriginous zones) where corticosteroid side effects are concerning 2, 5
• Pimecrolimus 1% cream applied twice daily is FDA-approved and effective, with 35% of patients achieving clear or almost clear skin at 6 weeks versus 18% with vehicle 5
• The main adverse event is transient burning sensation during the first days of treatment 5, 6

Proactive Maintenance Therapy to 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 areas to reduce subsequent flares. 3, 1, 7, 2

• This proactive approach represents a paradigm shift from purely reactive treatment and significantly lengthens time to relapse 3, 1
• Continue liberal emollient use to all skin during maintenance 1

Adjunctive Measures During Active Disease

Managing Pruritus

• Sedating antihistamines may provide short-term benefit during severe flares primarily through sedative properties to improve sleep, not through direct antipruritic effects 3, 1
• Non-sedating antihistamines have little to no value in atopic dermatitis management 1

Treating Secondary Infections

• Monitor for bacterial infection suggested by crusting or weeping; obtain bacteriological swabs if patients fail to respond to treatment 3
• Treat confirmed bacterial infections with appropriate systemic antibiotics (flucloxacillin for S. aureus, phenoxymethylpenicillin for streptococci, or erythromycin for penicillin allergy) 2
• Watch for eczema herpeticum (grouped, punched-out erosions or vesiculation), which requires prompt antiviral therapy 3, 1

Patient Education

Structured educational programs are strongly recommended as adjuncts to conventional therapy, as they significantly improve outcomes. 3, 1, 2

• Provide adequate time for explanation and discussion about the disease and treatment application techniques 3
• Have a nurse demonstrate proper application of topical preparations and explain quantities to use 3
• Address "steroid phobia" directly through education about benefits and risks of topical corticosteroids, as fear of steroids is a major cause of treatment non-adherence 3
• Provide written information to reinforce verbal discussions 3

Allergy Testing: When and When Not

Do not perform routine allergy testing without clinical history suggesting specific allergies. 3, 1, 2

• Allergy testing independent of history is not recommended 3, 2
• Consider patch testing only in persistent/recalcitrant disease or when allergic contact dermatitis is suspected 3, 2
• Do not implement food elimination diets based solely on allergy test results without documented clinical reactions 1, 2

Second-Line Treatment: Phototherapy

When first-line topical therapies fail after appropriate trial, phototherapy is the next step before considering systemic agents. 1, 7, 2

• Narrowband UVB is the preferred modality due to superior efficacy, safety profile, and availability 7, 2
• Phototherapy is indicated for moderate-to-severe atopic dermatitis refractory to optimized topical therapy 7, 2
• Maintenance typically requires once-weekly treatment indefinitely for many patients after initial clearance 2

Third-Line Treatment: Systemic Therapy

For moderate-to-severe atopic dermatitis failing phototherapy or when phototherapy is not viable, dupilumab, tralokinumab, or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) are strongly recommended. 1, 7, 2

Specific Agents

• Dupilumab: FDA-approved for patients ≥6 months old; dosing is 600 mg loading dose, then 300 mg every 2 weeks 2
• Tralokinumab: Strongly recommended for moderate-to-severe disease 7, 2
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib): All receive strong recommendations for moderate-to-severe disease 1, 7, 2

When to Refer to Dermatology

Refer when any of the following occur: 1

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

Special Considerations by Age

• Infants: Use only mild-potency corticosteroid preparations due to high body surface area-to-volume ratio and increased systemic absorption risk 1
• Adolescents: Can tolerate moderate-potency preparations on the body more safely than younger children due to lower systemic absorption risk 1