What is the recommended treatment regimen for a typical patient with atopic dermatitis of any age, including first‑line skin care, topical anti‑inflammatory therapy, and second‑line options?

Atopic Dermatitis Treatment

For all patients with atopic dermatitis, begin with liberal emollient application multiple times daily as the foundation, then add topical corticosteroids as first-line anti-inflammatory therapy for active disease, with potency selected by anatomic location—mild potency for face/intertriginous areas and mild-to-moderate potency for body/extremities. 1

First-Line Skin Care (Foundation for All Patients)

Emollients and Bathing

• Apply emollients liberally and frequently throughout the day to restore barrier function and maintain skin hydration 1
• Apply emollients immediately after bathing while skin is still damp to maximize moisture retention 2
• Replace regular soaps with soap-free cleansers to prevent removal of natural skin lipids 2
• Bathing for treatment and maintenance is conditionally recommended, though optimal frequency and duration remain undefined 1

First-Line Anti-Inflammatory Therapy

Topical Corticosteroids (Primary Treatment)

• Use topical corticosteroids as first-line pharmacologic treatment for active disease flares 1
• Apply once daily to affected areas until the flare resolves 2
• Select potency based on anatomic location: 1
  • Face and intertriginous areas: mild potency only (Class VI-VII)
  • Body and extremities: mild-to-moderate potency (Class III-V)
  • Avoid high-potency steroids on the face—this causes skin atrophy 2
• Use the least potent preparation that controls the eczema 2

Topical Calcineurin Inhibitors (Steroid-Sparing Option)

• Tacrolimus 0.03% or 0.1% ointment is strongly recommended for adults with AD 1
• Pimecrolimus 1% cream is strongly recommended for adults with mild-to-moderate AD 1
• Use particularly for sensitive areas (face, neck, genitals, body folds) where corticosteroid side effects are concerning 2
• Can be used in conjunction with topical corticosteroids as first-line treatment 2
• Long-term safety data show no clinically meaningful cancer risk despite FDA black box warning 1

Newer Topical Agents

• Crisaborole (PDE-4 inhibitor) ointment is strongly recommended for adults with mild-to-moderate AD 1
• Ruxolitinib (JAK inhibitor) cream is strongly recommended for adults with mild-to-moderate AD 1

Proactive Maintenance Therapy (Prevent Flares)

After achieving disease control, continue anti-inflammatory therapy intermittently to previously affected areas to reduce subsequent flares—this represents a paradigm shift from purely reactive treatment. 1, 2

• Apply topical corticosteroids (medium potency) 1-2 times weekly to previously affected areas 1
• Alternatively, apply topical calcineurin inhibitors 2-3 times weekly to previously affected areas 2
• This proactive approach significantly reduces flares and lengthens time to relapse 1, 2

Adjunctive Measures During Flares

Wet Wrap Therapy

• For moderate-to-severe AD experiencing a flare, wet dressings with topical corticosteroids are conditionally recommended 1
• Requires patient education for proper technique and is time-intensive 1
• Most evidence is from pediatric populations 1

Antihistamines

• Sedating antihistamines may provide short-term benefit during severe flares primarily through sedation to improve sleep, not direct antipruritic effects 2
• Non-sedating antihistamines have little to no value in AD management 2
• Topical antihistamines are conditionally recommended against 1

Infection Management

• Monitor for secondary bacterial infection requiring appropriate antibiotic treatment 2
• Watch for eczema herpeticum requiring prompt antiviral therapy 2
• Topical antimicrobials and antiseptics are conditionally recommended against for routine use 1
• Bleach baths may be considered for moderate-to-severe AD with clinical signs of secondary bacterial infection 1

When to Escalate to Second-Line Therapy

Criteria for Systemic Therapy Consideration

Before advancing to systemic therapy, complete this systematic assessment: 1

• Rule out alternate or concomitant diagnoses (allergic contact dermatitis, cutaneous lymphoma) 1
• Optimize topical therapy and ensure adequate patient education 1
• Treat any coexistent infection 1
• Assess impact on quality of life using validated tools 1
• Consider phototherapy as next step before systemic agents 1, 2

Phototherapy

• Phototherapy is conditionally recommended for adults with AD refractory to optimized topical therapy 1
• Use when topical regimens fail and before advancing to systemic medications 2

Systemic Therapies (For Moderate-to-Severe Refractory Disease)

Strong recommendations are made for: 1

• Dupilumab (IL-4 receptor inhibitor)
• Tralokinumab (IL-13 inhibitor)
• Abrocitinib (JAK inhibitor)
• Baricitinib (JAK inhibitor)
• Upadacitinib (JAK inhibitor)

Conditional recommendations in favor of: 1

• Azathioprine
• Cyclosporine
• Methotrexate
• Mycophenolate

Conditional recommendation against: 1

• Systemic corticosteroids

Critical Pitfalls to Avoid

• Do not perform routine allergy testing without clinical history suggesting specific allergies 2
• Do not implement food elimination diets based solely on allergy test results without documented clinical reactions 2
• Do not continue ineffective first-line treatment indefinitely—escalate therapy or refer to dermatology if no improvement occurs after appropriate trial 2
• Never use potent topical corticosteroids on the face—this causes skin atrophy and other complications 2
• Do not use topical corticosteroids reactively only—implement proactive maintenance therapy after achieving control 1, 2

When to Refer to Dermatology

Refer when: 2

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

Special Age Considerations

• Infants: use only mild-potency topical corticosteroids due to high body surface area-to-volume ratio increasing systemic absorption risk 2
• Adolescents: can tolerate moderate-potency preparations on the body more safely than younger children 2