What is the recommended first‑line topical treatment regimen for adult atopic dermatitis (eczema)?

First-Line Topical Treatment for Adult Atopic Dermatitis

For adults with atopic dermatitis, begin with liberal daily moisturizers combined with topical corticosteroids as the primary anti-inflammatory agent, selecting potency based on body site—medium-potency for trunk and extremities, low-potency (hydrocortisone 1-2.5%) for face, groin, and axillae. 1, 2

Foundation: Moisturizers and Skin Barrier Repair

• Apply moisturizers liberally after every bath to all skin, regardless of disease severity—this is non-negotiable baseline therapy that hydrates skin and repairs the compromised barrier. 1, 2
• Apply emollients to damp skin within 10-15 minutes of bathing to create a surface lipid film that reduces transepidermal water loss. 3
• Use soap-free cleansers or dispersible creams instead of regular soaps, which strip natural lipids and worsen barrier dysfunction. 2, 3
• Continue aggressive emollient use even during clear periods—this provides steroid-sparing benefits and extends recurrence-free intervals. 3

First-Line Pharmacologic Treatment: Topical Corticosteroids

Potency Selection by Body Site

• For trunk and extremities: Use medium-potency topical corticosteroids (e.g., mometasone furoate, triamcinolone acetonide) applied no more than twice daily during flares. 1, 2, 3
• For face, groin, and axillae: Use only low-potency preparations (hydrocortisone 1-2.5%) because these thin-skinned areas are highly prone to steroid-induced atrophy and telangiectasia. 2, 3
• Apply the lowest potency that achieves disease control—this minimizes adverse effects while maintaining efficacy. 1, 3

Application Strategy

• During acute flares, apply twice daily until improvement is seen (typically 2-4 weeks). 2, 3
• After achieving clearance, transition to proactive maintenance therapy: apply the same topical corticosteroid twice weekly to previously affected areas to prevent flares and extend remission. 1, 2, 3
• Incorporate short "steroid holidays" when feasible to reduce the risk of skin atrophy, even on the extremities. 3
• Choose ointment formulations for very dry skin, creams for non-greasy daily use, and lotions for hairy areas. 3

Alternative First-Line Option: Topical Calcineurin Inhibitors

• Tacrolimus 0.03% or 0.1% ointment and pimecrolimus 1% cream are strongly recommended as first-line alternatives, particularly valuable for sensitive areas (face, groin, axillae) where steroid atrophy is a concern. 1, 2
• Tacrolimus is as effective as class III-V topical corticosteroids for trunk and extremities, and more effective than low-potency corticosteroids for facial or neck involvement. 4
• These agents can be used 2-3 times per week as proactive maintenance after disease stabilization in patients where corticosteroid-related concerns exist. 3
• The main adverse event is transient burning or increased pruritus at application sites, typically observed only during the first days of treatment. 5

Additional First-Line Options (Newer Agents)

• Crisaborole ointment (PDE-4 inhibitor) and ruxolitinib cream (JAK inhibitor) are strongly recommended as first-line options for mild-to-moderate atopic dermatitis. 1, 2

Adjunctive Measures During Flares

• For moderate-to-severe flares, wet wrap therapy can be conditionally recommended to enhance topical medication penetration and provide cooling relief. 1, 2
• Sedating antihistamines (hydroxyzine, diphenhydramine) may be used short-term for nighttime itching through their sedative properties—not through direct antipruritic effects—but they must not replace topical anti-inflammatory therapy. 3, 6
• Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be prescribed. 3

Critical Pitfalls to Avoid

• Do not use topical antimicrobials, antiseptics, or antihistamines routinely—these are conditionally recommended against except in specific circumstances (e.g., bleach baths for moderate-to-severe disease with clinical signs of secondary bacterial infection). 1, 2
• Do not delay or withhold topical corticosteroids when secondary bacterial infection is present—continue them concurrently with appropriate systemic antibiotics (flucloxacillin first-line for Staphylococcus aureus). 3
• Avoid very potent corticosteroids in thin-skinned areas or continuous daily use without breaks. 3
• Address steroid phobia directly: educate patients that low-potency topical corticosteroids are safe for facial use when applied correctly, as fear often leads to undertreatment. 3

When to Escalate Beyond First-Line Therapy

• If inadequate response after 4-8 weeks of optimized topical therapy (appropriate potency, adequate duration, consistent emollient use), consider escalation to phototherapy (narrowband UVB) or systemic therapies (dupilumab, JAK inhibitors, traditional immunosuppressants). 2, 3
• Refer urgently if eczema herpeticum is suspected (grouped vesicles, punched-out erosions, sudden deterioration with fever)—this is a medical emergency requiring immediate oral or intravenous acyclovir. 3