What is the recommended treatment approach for atopic dermatitis, including topical therapies, phototherapy, and systemic options?

Treatment of Atopic Dermatitis

Stepwise Treatment Algorithm

For most patients with atopic dermatitis, begin with emollients and topical corticosteroids; escalate to phototherapy for inadequate response, then to dupilumab, tralokinumab, or JAK inhibitors for severe or refractory disease. 1

Mild Disease (Limited Body Surface Area)

• Apply emollients liberally at least twice daily, immediately after bathing to lock in moisture and restore the compromised skin barrier 2, 3
• Use low-potency topical corticosteroids (hydrocortisone 1-2.5%) for flares, applied no more than twice daily to affected areas 2, 3
• Substitute all soaps with soap-free cleansers to avoid stripping natural lipids 3
• For facial involvement, limit hydrocortisone 1-2.5% to 2-4 weeks of continuous use, then implement "steroid holidays" to prevent atrophy 3

Moderate Disease (More Extensive Involvement)

• Continue aggressive emollient therapy as the foundation of all treatment 2
• Escalate to medium-potency topical corticosteroids (e.g., mometasone furoate, triamcinolone acetonide) for body areas, applied twice daily during flares 2
• After achieving clearance (typically 2-4 weeks), transition to proactive maintenance therapy: apply the same topical corticosteroid twice weekly to previously affected areas to prevent relapses 3
• Consider topical calcineurin inhibitors (tacrolimus or pimecrolimus) as steroid-sparing agents, particularly for sensitive areas like the face, eyelids, and genitals 2, 4

Severe or Refractory Disease

When moderate-potency topical corticosteroids fail after 4 weeks of appropriate use, escalate to phototherapy or systemic therapy. 3

Phototherapy (Second-Line)

• Narrowband UVB (312 nm) is the preferred phototherapy modality due to superior efficacy, safety profile, and widespread availability 1, 2
• Phototherapy should only be initiated after confirming failure of optimized topical therapy (adequate potency, duration, and concurrent emollient use) 3
• Avoid phototherapy in children under 12 years due to unclear long-term safety, particularly concerns about premature skin aging and cutaneous malignancies 5
• Dose based on minimal erythema dose (MED) or Fitzpatrick skin type; start at 50% of MED and increase by 10% of initial MED for treatments 1-20 1

Systemic Therapy (Third-Line)

The American Academy of Dermatology issues strong recommendations for five systemic agents based on high-quality evidence:

• Dupilumab (IL-4/IL-13 inhibitor): Strongly recommended as first-line systemic therapy with excellent efficacy and safety profile after 5+ years in clinical practice 1, 2, 5
• Tralokinumab (IL-13 inhibitor): Strongly recommended as an alternative biologic option 1, 2, 5
• JAK inhibitors (abrocitinib, baricitinib, upadacitinib): All three are strongly recommended for moderate-to-severe disease 1, 2, 5

Conditional recommendations (second-line systemic options):

• Cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil receive conditional recommendations due to lower-quality evidence from smaller trials 1, 5
• These older immunosuppressants require more rigorous monitoring for adverse effects compared to biologics 1

Systemic corticosteroids receive a conditional recommendation AGAINST their use except for very short-term "tiding over" during acute severe flares, due to risks of pituitary-adrenal suppression and rebound flares upon discontinuation 1, 3

Management of Secondary Infections

Bacterial Superinfection (Most Common: Staphylococcus aureus)

• Suspect bacterial infection when you observe increased crusting, weeping, purulent exudate, or pustules 3
• Prescribe oral flucloxacillin as first-line antibiotic; use erythromycin for penicillin allergy 3
• Critical: Do not discontinue topical corticosteroids during bacterial infection—continue them concurrently with appropriate systemic antibiotics 3
• Obtain bacterial cultures if the skin fails to improve after initial antibiotic treatment 3

Eczema Herpeticum (Medical Emergency)

• Recognize this emergency by grouped vesicles, punched-out erosions, or sudden deterioration with fever 3
• Initiate oral acyclovir immediately; use intravenous acyclovir for febrile or systemically ill patients 3
• Early antiviral initiation shortens hospital stays and improves outcomes 3

Adjunctive Therapies

Antihistamines

• Sedating antihistamines (hydroxyzine, diphenhydramine) may provide short-term relief of nighttime itch through sedative effects, not direct antipruritic action 1, 3
• Non-sedating antihistamines have no proven benefit for atopic dermatitis pruritus and should not be routinely prescribed 3
• Reserve antihistamines for patients with concurrent urticaria or allergic rhinoconjunctivitis 2

Systemic Antibiotics

• Use systemic antibiotics only when clinical evidence of bacterial infection exists—not for colonized or non-infected eczematous skin 2, 3
• Empiric antibiotics in non-infected skin promote resistance without clinical benefit 3

Common Pitfalls to Avoid

• Steroid phobia leads to undertreatment: Educate patients that low-to-moderate potency topical corticosteroids are safe when used appropriately 3
• Delaying topical corticosteroids during infection: Continue topical steroids when appropriate systemic antibiotics are given concurrently 3
• Using very potent corticosteroids on thin-skinned areas: Avoid potent/very potent preparations on face, neck, flexures, and genitals where atrophy risk is highest 3
• Continuous daily corticosteroid use without breaks: Implement twice-weekly proactive maintenance after clearance rather than daily continuous use 3
• Ignoring emollients during clear periods: Aggressive emollient use provides steroid-sparing benefits and extends recurrence-free intervals 3

When to Refer or Escalate

• Failure to respond to moderate-potency topical corticosteroids after 4 weeks of appropriate use 3
• Need for phototherapy or systemic therapy 3
• Suspected eczema herpeticum (immediate referral) 3
• Atypical presentations or diagnostic uncertainty 3