What is the recommended management for atopic dermatitis?

Management of Atopic Dermatitis

All patients with atopic dermatitis require a foundation of daily moisturizers combined with topical anti-inflammatory therapy (corticosteroids or calcineurin inhibitors) for active lesions, followed by mandatory proactive maintenance therapy with twice-weekly application of these agents to previously affected areas—never discontinue treatment completely after flare resolution. 1, 2

Diagnosis and Clinical Assessment

• Establish diagnosis clinically based on three essential features: pruritus, chronic/relapsing course, and characteristic distribution (facial/neck/extensor involvement in infants; flexural lesions at any age; sparing of groin/axillary regions) 1
• Do not order IgE levels for diagnosis or routine severity assessment—they are not recommended 1
• Skip formal disease severity scales in routine practice; instead directly assess itch intensity, sleep disruption, impact on daily activities, and disease persistence 1
• Screen for associated conditions including asthma, rhinitis/rhinoconjunctivitis, food allergies, sleep disturbance, depression, and neuropsychiatric conditions 1

Foundation Therapy (Required for ALL Patients)

Skin Barrier Repair

• Apply ceramide-containing moisturizers liberally immediately after bathing to repair barrier dysfunction 1, 2
• Use warm (not hot) water with limited bathing duration 1
• Use only neutral pH, fragrance-free, hypoallergenic cleansers—avoid alkaline soaps 1
• Eliminate all products containing fragrances and preservatives 1

Treatment Algorithm by Disease Severity

Step 1: Active Flares (First-Line)

• Apply topical corticosteroids twice daily during active flares, selecting potency based on anatomic site 1, 2
  • Lower potency for face, genitals, intertriginous areas
  • Higher potency for trunk, extremities, or severe inflammation 2
• Continue until improvement is seen, then transition immediately to maintenance therapy 2

Step 2: Mandatory Maintenance Therapy (After Achieving Control)

This is the critical step that prevents recurrence—never skip this phase 1, 2

Choose one of two options:

• Topical corticosteroids 1-2 times per week to previously affected areas 1, 2
• OR topical calcineurin inhibitors 2-3 times per week to previously affected areas 1, 2

Continue daily moisturizers throughout maintenance phase 1, 2

Step 3: Phototherapy (If Topical Regimens Fail After Optimization)

• Narrowband UVB is generally preferred for favorable efficacy and safety profile 1, 2

Step 4: Systemic Therapy (For Severe Disease or Phototherapy Failure)

Preferred options based on strongest evidence:

• Dupilumab (biologic): FDA-approved for moderate-to-severe atopic dermatitis in patients ≥6 months whose disease is not adequately controlled with topical therapies 3
  • Initial dose: 600 mg (two 300 mg injections at different sites) for adults 3
  • Can be used with or without topical corticosteroids 3
• JAK inhibitors: Abrocitinib, baricitinib, or upadacitinib receive strong recommendations for severe chronic disease 1, 2
• Traditional immunosuppressants: Cyclosporine, azathioprine, methotrexate, or mycophenolate 1, 2

Adjunctive Interventions

Educational Programs (Strongly Recommended for ALL Patients)

• Incorporate structured educational programs ("eczema schools") as adjunct to conventional therapy—these significantly improve treatment outcomes 1, 2
• Video interventions and nurse-led programs are beneficial adjuncts 1
• Use integrated, multidisciplinary approach for patients with comorbid conditions 1

Infection Management

• Use systemic antibiotics ONLY when clinical evidence of bacterial infection exists (purulent exudate, pustules)—not for colonization or non-infected dermatitis 4, 1, 2
• Obtain skin culture with antibiotic susceptibility for recurrent or non-responsive infections 4
• Use systemic antiviral agents (acyclovir) immediately for eczema herpeticum—this is a dermatologic urgency with historically 10-50% mortality if untreated 4, 1
• Consider dilute bleach baths (0.005% sodium hypochlorite) twice weekly for infection-prone patients 2

Allergy Testing: When and What to Test

Perform allergy testing ONLY when specific concerns are identified during history taking 1, 2

• Consider food allergy evaluation (milk, egg, peanut, wheat, soy) ONLY in children <5 years with moderate-to-severe disease IF:
  • Persistent disease despite optimized treatment, OR
  • Reliable history of immediate reaction after specific food ingestion 1, 2
• Do NOT recommend food elimination diets based solely on allergy test results 1, 2
• Consider patch testing in patients with persistent or recalcitrant disease to rule out allergic contact dermatitis 2

Critical Pitfalls to Avoid

What NOT to Do:

• Never discontinue all therapy after acute flare resolution—this leads to recurrence; always transition to proactive maintenance 1, 5, 2
• Do not rely on oral antihistamines as primary treatment for itch—they do not reduce pruritus in atopic dermatitis (though may help with sleep disturbance) 1, 2, 6
• Do not use systemic antibiotics without documented infection—antibiotics for colonization increase resistance without improving disease outcomes 4, 1, 2
• Do not recommend probiotics/prebiotics—evidence is inconsistent for established disease 1
• Do not recommend dietary supplements (fish oils, evening primrose oil, borage oil, multivitamins, zinc, vitamin D, vitamin E, vitamin B12/B6)—insufficient evidence 1
• Do not use sublingual or injection immunotherapy in the general atopic dermatitis population—conflicting conclusions from limited studies 1
• Do not recommend alternative therapies (Chinese herbal therapy, massage therapy, aromatherapy, naturopathy, hypnotherapy, acupressure, autologous blood injections)—insufficient evidence 1
• Avoid long-term potent topical corticosteroids on sensitive areas (face, genitals) due to high risk of atrophy—use topical calcineurin inhibitors instead 5, 2