What is the best treatment approach for a patient with atopic dermatitis?

Management of Atopic Dermatitis

The best treatment approach for atopic dermatitis is a stepwise algorithm starting with liberal emollient application and soap-free cleansers for all patients, followed by topical corticosteroids as first-line anti-inflammatory therapy for active disease, with escalation to phototherapy for refractory cases, and finally systemic biologics (dupilumab, tralokinumab) or JAK inhibitors (abrocitinib, baricitinib, upadacitinib) for moderate-to-severe disease that fails phototherapy. 1, 2, 3

Foundation: Skin Barrier Repair (Required for All Patients)

• Apply emollients liberally and frequently throughout the day, immediately after bathing while skin is still damp, to maximize moisture retention and improve barrier function 1, 2, 3
• Adults require at least 250 grams of emollient per week to achieve adequate skin hydration 4
• Replace all regular soaps with soap-free cleansers or dispersible cream substitutes, as traditional soaps strip natural lipids and worsen xerosis 5, 1
• Use warm (not hot) water with limited bathing duration, followed immediately by emollient application 3
• Bath oils are beneficial for cleansing and hydrating when combined with immediate post-bath emollient use 5

First-Line Anti-Inflammatory Treatment for Active Disease

• Topical corticosteroids are the mainstay of treatment for atopic dermatitis flares and should be applied once daily to affected areas until the flare resolves 5, 2
• Select corticosteroid potency strictly by anatomic location: use only low-potency preparations for face and intertriginous areas, medium-potency for trunk and extremities in moderate disease, and reserve very potent preparations for thick, lichenified areas with limited duration 1, 2
• Critical pitfall to avoid: Never use potent topical corticosteroids on the face, as this leads to skin atrophy and other serious complications 2
• Use the least potent preparation required to control the eczema, and when possible, stop corticosteroids for short periods 5
• Topical calcineurin inhibitors (pimecrolimus, tacrolimus) can be used in conjunction with topical corticosteroids as first-line treatment, particularly for sensitive areas like the face where steroid side effects are concerning 2, 6, 7

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 and lengthen time to relapse 1, 2, 3
• This proactive approach represents a paradigm shift from purely reactive treatment and keeps patients in control of their disease 2, 8
• Combine maintenance therapy with ceramide-containing moisturizers applied immediately after bathing 3

Trigger Avoidance and Environmental Modifications

• Keep nails short to minimize damage from scratching 5
• Avoid extremes of temperature and irritant clothing such as wool worn next to the skin; cotton clothing is preferred 5
• Eliminate products containing fragrances and preservatives that can exacerbate inflammation 3
• Identify and avoid patient-specific trigger factors such as allergens, stress, microbial pathogens, or skin irritants 4

Management of Secondary Infections

• Bacterial infection is suggested by crusting or weeping; treat overt bacterial infection with systemic antibiotics such as flucloxacillin for S. aureus, phenoxymethylpenicillin for streptococci, or erythromycin for penicillin allergy 5, 1
• Grouped, punched-out erosions or vesiculation indicate herpes simplex infection (eczema herpeticum), which requires prompt systemic antiviral therapy 5, 1, 6
• Bacteriological swabs are not routinely indicated but may be necessary if patients do not respond to treatment 5

Second-Line Treatment: Phototherapy

• Phototherapy is indicated for moderate-to-severe atopic dermatitis refractory to optimized topical therapy with emollients and topical anti-inflammatory agents 1, 2, 7
• Narrowband UVB is the preferred modality due to superior efficacy, safety profile, and availability compared to PUVA or broadband UVB 1
• Maintenance typically requires once-weekly treatment indefinitely for many patients after initial clearance 1

Third-Line Treatment: Systemic Therapy

• Dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib all receive strong recommendations for moderate-to-severe atopic dermatitis failing phototherapy or when phototherapy is not viable 1, 2, 4
• Dupilumab is FDA-approved for moderate-to-severe atopic dermatitis in patients ≥6 months old, with dosing of 600 mg loading dose, then 300 mg every 2 weeks 1
• Traditional immunosuppressants (cyclosporine, azathioprine, methotrexate, mycophenolate) remain options for severe disease 3, 4

Patient Education (Essential Component)

• Structured educational programs ("eczema schools") are strongly recommended as adjuncts to conventional therapy, as they significantly improve outcomes by teaching disease recognition, trigger avoidance, proper medication application, and moisturization techniques 1, 2, 3
• Allow adequate time for explanation and discussion; demonstrate how to apply treatments and provide written information to reinforce issues discussed 5
• Address topical steroid phobia through education about benefits and risks of different potencies 5, 2

Allergy Testing: When and When Not to Test

• Perform allergy testing only when specific concerns are identified during history taking, such as hives, urticaria, or immediate reactions after exposure 3
• Do not perform routine allergy testing without clinical history suggesting specific allergies 2, 3
• Consider food allergy evaluation for milk, egg, peanut, wheat, and soy only in children under 5 years with moderate-to-severe disease that persists despite optimized treatment, or with reliable history of immediate reaction after specific food ingestion 1, 3
• Do not implement food elimination diets based solely on allergy test results without documented clinical reactions 2, 3

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, though sedating antihistamines may provide short-term benefit during severe flares primarily through sedative properties to improve sleep 2, 3, 7
• Non-sedating antihistamines have little to no value in atopic dermatitis management 2
• Do not use probiotics/prebiotics—evidence is inconsistent for established disease 3
• Do not recommend dietary supplements (fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12/B6)—insufficient evidence 3
• Do not use sublingual or injection immunotherapy in the general atopic dermatitis population—conflicting conclusions from limited studies 3
• Do not discontinue all therapy after acute flare resolution—this leads to recurrence; continue proactive maintenance therapy 3
• Avoid using potent topical corticosteroids continuously for long periods or on large body surface areas without breaks 5

When to Refer to Dermatology

• Refer when failure to respond to first-line treatment occurs, diagnostic uncertainty exists, second-line treatments (phototherapy or systemic therapy) are being considered, or disease significantly impacts quality of life 2
• Consider referral if deterioration occurs in previously stable disease, which may indicate secondary bacterial or viral infection or development of contact dermatitis 5

Special Considerations by Age

• Infants are particularly susceptible to topical corticosteroid side effects due to high body surface area-to-volume ratio—use only mild-potency preparations 2
• Pimecrolimus is FDA-approved for patients 2 years and older with mild to moderate atopic dermatitis; do not use on children under 2 years old 6
• Adolescents have lower systemic absorption risk and can tolerate moderate-potency preparations on the body more safely than younger children 2