What is the best approach to manage atopic dermatitis in a patient?

Management of Atopic Dermatitis

Apply ceramide-containing moisturizers immediately after bathing and use topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) as maintenance therapy to previously affected areas after achieving disease control to prevent flares. 1, 2, 3

Diagnosis and Initial Assessment

Establish diagnosis clinically based on essential features: pruritus, chronic/relapsing course, and characteristic morphology/distribution (facial/neck/extensor involvement in infants; flexural lesions in any age group; sparing of groin/axillary regions). 4

• Do not order IgE levels for diagnosis or routine severity assessment—they are not recommended. 4
• Skin biopsy, KOH preparation, or genetic testing may occasionally help rule out other conditions, but are not routinely needed. 4
• Skip formal disease severity scales in routine practice; instead ask directly about itch, sleep disruption, impact on daily activities, and disease persistence. 4

Screen for associated conditions including asthma, rhinitis/rhinoconjunctivitis, food allergies, sleep disturbance, depression, and neuropsychiatric conditions—discuss these as part of the treatment plan. 4

Foundation: Skin Barrier Repair (All Patients)

Daily ceramide-containing moisturizers are essential for both acute treatment and long-term maintenance, applied immediately after bathing to lock in moisture. 1, 2

• Use warm (not hot) water with limited bathing duration. 2
• Avoid soaps with alkaline pH; use neutral pH, fragrance-free, hypoallergenic cleansers. 2
• Eliminate products containing fragrances and preservatives that can exacerbate inflammation. 1, 2

Treatment Algorithm by Disease Severity

Mild-to-Moderate Disease

Topical corticosteroids are first-line for active lesions, with potency selected based on anatomic site. 1, 3, 5

• Topical calcineurin inhibitors (pimecrolimus or tacrolimus) can be used in conjunction with topical corticosteroids, particularly for sensitive sites like the face where potent corticosteroids are potentially harmful. 6, 5
• Apply pimecrolimus cream twice daily to affected skin; stop when signs/symptoms resolve. 6
• If symptoms persist beyond 6 weeks, re-examine to confirm diagnosis. 6
• Avoid continuous long-term use and occlusive dressings with topical calcineurin inhibitors. 6

After achieving acceptable clearance, transition immediately to maintenance therapy—do not discontinue topical therapy completely. 1, 3, 7

• Maintenance options: topical corticosteroids 1-2× per week OR topical calcineurin inhibitors 2-3× per week to previously involved skin. 4, 1, 3
• This proactive approach significantly reduces subsequent flares. 4, 1, 3

Moderate-to-Severe Disease

If topical regimens fail after optimization, advance to phototherapy—narrowband UVB is generally preferred for its favorable efficacy and safety profile. 1, 5

For inadequate response to phototherapy or severe disease, initiate systemic therapy:

• Biologics (preferred): Dupilumab or tralokinumab receive strong recommendations as they target key inflammatory pathways. 1
• JAK inhibitors: Abrocitinib, baricitinib, or upadacitinib also receive strong recommendations. 1
• Traditional immunosuppressants (conditional recommendations): Cyclosporine (1-4 mg/kg/day), azathioprine, methotrexate, or mycophenolate may be considered. 1, 3
• Avoid systemic corticosteroids for long-term management due to rebound risk. 1, 8

Educational Interventions (All Patients)

Incorporate educational programs ("eczema schools") as adjunct to conventional therapy—these significantly improve treatment outcomes. 4, 1, 3

• Video interventions and nurse-led programs are also beneficial adjuncts. 4
• An integrated, multidisciplinary approach is valuable for patients with common comorbid associations. 4

Allergy Assessment and Testing

Perform allergy testing only when specific concerns are identified during history taking (e.g., hives, urticaria, immediate reactions). 4, 1, 3

• Allergy testing independent of clinical history is not recommended. 4, 1
• Do not recommend food elimination diets based solely on allergy test results. 4, 1, 3

For children under 5 years with moderate-to-severe disease, consider food allergy evaluation for milk, egg, peanut, wheat, and soy only if:

• Persistent disease despite optimized treatment, OR
• Reliable history of immediate reaction after specific food ingestion. 4, 1, 3

Consider patch testing in patients with persistent/recalcitrant disease or physical exam findings suggesting allergic contact dermatitis. 4, 1, 3

Adjunctive Treatments

Use systemic antibiotics only when clinical evidence of bacterial infection exists—not for non-infected atopic dermatitis. 3, 5

Use systemic antiviral agents for eczema herpeticum. 3

Bleach baths and wet dressings may be used as adjunctive treatments during flares. 9

Special Consideration: Concurrent Sinusitis

For patients with both atopic dermatitis and sinusitis, dupilumab is particularly beneficial as it targets the Th2 inflammatory pathway underlying both conditions. 1

What NOT to Do: Common Pitfalls

• Do not rely on oral antihistamines as primary treatment for itch—they do not reduce pruritus in atopic dermatitis. 1, 3
• Do not use probiotics/prebiotics—evidence is inconsistent for established disease. 4, 3
• Do not recommend dietary supplements (fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12/B6)—insufficient evidence. 4, 3
• Do not use sublingual or injection immunotherapy in the general atopic dermatitis population—conflicting conclusions from limited studies. 4, 3
• Do not recommend alternative therapies (Chinese herbal therapy, massage therapy, aromatherapy, naturopathy, hypnotherapy, acupressure, autologous blood injections)—insufficient evidence. 4, 3
• Do not discontinue all therapy after acute flare resolution—this leads to recurrence. 1, 2, 3