Atopic Dermatitis Management
ATOPIC DERMATITIS MANAGEMENT
Therapy   Strength Dosage form Dosing/frequency Recommendations
NONPHARMACOLOGIC
Topical moisturizers Emollients (glycol and glyceryl stearate, soy sterols) crm, oint, gel, lotion, oil Liberal and frequent reapplication. Apply soon after bathing to improve skin hydration.

• Mild AD: main primary treatment.

• Moderate to severe AD: incorporated into regimen.

Occlusives (petrolatum, dimethicone, mineral oil)
Humectants (glycerol, lactic acid, urea)
Prescription emollient devices Palmitoylethanolamide-, glycyrrhetinic acid-, or other hydrolipid-containing preparations crm 2–3 times daily.

• Adjunct to treatment and maintenance.

• More costly than topical moisturizers but not superior.

Bathing Water Once daily for 5–10mins (warm water). Apply moisturizer immediately after bathing. Severely inflamed skin: up to 20mins; apply topical anti-inflammatory therapies (TCS) immediately after without towel drying.

• Use of nonsoap-based surfactants and synthetic detergents (syndets) are often recommended.

• Limit use of neutral-to-low pH, hypoallergenic, and fragrance-free nonsoap cleansers.

• Limited data on the addition of oils, emollients, and other related additives to bath water, and the use of acidic spring water (balneo-therapy) and water-softening devices; not recommended.

Wet-wrap therapy Topical agent covered by wetted first layer (tubular bandage, gauze, cotton suit) and dry second layer Up to 24hrs at a time for up to 2wks.

• For significant flares and/or recalcitrant disease.

• Use with or without TCS for moderate to severe AD (caution with medium to higher potency TCS).1

Phototherapy UVB Narrowband (309–312nm) Administer to affected areas 2–5 times weekly

• Last-line therapy for non-immunocompromised patients with topical treatment failure.

PHARMACOLOGIC2
Topical Corticosteroids3
Very high potency augmented betamethasone dipropionate (oint) 0.05% crm, oint, lotion, foam, soln, gel Treatment: apply twice daily until lesions improve, for up to 2–4wks at a time; for high potency TCS, may apply once daily. Use 0.5g for an area of 2 adult palms. Maintenance: apply 1–2 times weekly for frequent, repeated flares at same site.

• First-line pharmacologic therapy for mild to moderate AD if uncontrolled by moisturizers or irritant avoidance.

• Use concomitantly with moisturizers.

• Use least potent TCS that is effective.

• Lower potency TCS should be used on the face and skin folds and medium to high potency TCS on the body.

• Monitor cutaneous side-effects during long-term, potent steroid use. Routine monitoring of systemic effects is not recommended.

clobetasol propionate 0.05%
diflorasone diacetate (oint) 0.05%
halobetasol propionate 0.05%
High potency amcinonide 0.1%
augmented betamethasone dipropionate (crm) 0.05%
betamethasone dipropionate 0.05%
desoximetasone 0.25%
desoximetasone (gel) 0.05%
diflorasone diacetate (crm) 0.05%
fluocinonide 0.05%
halcinonide 0.1%
mometasone furoate (oint) 0.1%
triamcinolone acetonide 0.5%
Medium potency betamethasone valerate 0.1%
clocortolone pivalate 0.1%
desoximetasone (crm) 0.05%
fluocinolone acetonide 0.025%
flurandrenolide 0.05%
fluticasone propionate 0.05%, 0.005%
mometasone furoate (crm) 0.1%
triamcinolone acetonide 0.1%
Lower-medium potency hydrocortisone butyrate 0.1%
hydrocortisone probutate 0.1%
hydrocortisone valerate 0.2%
prednicarbate 0.1%
Low potency alclometasone dipropionate 0.05%
desonide 0.05%
fluocinolone acetonide 0.01%
Lowest potency hydrocortisone acetate 0.5–1%
hydrocortisone base 0.25–1%
Phosphodiesterase 4 (PDE4) Inhibitor
crisaborole Eucrisa 2% oint Mild to moderate: ≥3mos: apply a thin layer to affected areas twice daily.

• First-line treatment

Topical Calcineurin Inhibitors
tacrolimus Protopic 0.03%, 0.1% oint Moderate to severe: ≥2yrs4: apply a thin layer to affected areas twice daily. 2–15yrs: use 0.03% strength. ≥16yrs: use 0.03% or 0.1% strength. May use 2–3 times weekly as maintenance therapy to prevent recurrent flares.

• Second-line therapy for short-term and non-continuous chronic treatment of AD in non-immunocompromised patients with inadequate response to topical prescription therapies or when they are not advisable.

• Preferred for sensitive areas (eg, face, skin folds).

• Not recommended during active infections of lesions.

• May be combined with TCS sequentially or concomitantly.

• Long term safety has not been established due to association with skin malignancies and lymphoma; avoid continuous long-term use in any age group.

pimecrolimus Elidel 1% crm Mild to moderate: ≥2yrs4: apply a thin layer to affected areas twice daily. May use 2–3 times weekly as maintenance therapy to prevent recurrent flares.
Interleukin-4 Receptor Alpha Antagonist
dupilumab Dupixent 100mg/0.67mL, 200mg/1.14mL, 300mg/2mL SC inj Moderate to severe: 6–17yrs (15–<30kg): initially 600mg (two 300mg inj at different sites) followed by 300mg every 4wks; (30–<60kg): initially 400mg (two 200mg inj at different sites) followed by 200mg every other week; (≥60kg): initially 600mg followed by 300mg every other week. ≥18yrs: initially 600mg followed by 300mg every other week.

• Reserved for patients with inadequate response to topical prescription therapies or when they are not advisable.

• May use with or without TCS.

• Topical calcineurin inhibitors may also be used, but should be reserved only for problem areas (eg, face, neck, intertriginous and genital areas).

tralokinumab-ldrm Adbry 150mg/mL SC inj Moderate to severe: ≥18yrs: initially 600mg (four 150mg inj), followed by 300mg (two 150mg inj) every other week. After 16wks, may consider 300mg every 4wks for patients weighing <100kg who achieve clear or almost clear skin.
Janus Kinase Inhibitor5
abrocitinib Cibinqo 50mg, 100mg, 200mg tabs Moderate to severe: 100mg once daily; may increase to max 200mg once daily if inadequate response after 12wks.

• Reserved for refractory patients with inadequate response to other systemic therapies, including biologics, or when they are not advisable.

ruxolitinib Opzelura 1.5% crm Mild to moderate: ≥12yrs: apply a thin layer to the affected areas (up to 20% BSA) twice daily; max 60g/wk.

• For short-term and non-continuous chronic treatment of AD in non-immunocompromised patients with inadequate response to topical prescription therapies or when they are not advisable.

• Not recommended during active infections, and for use with biologics, other JAK inhibitors, or potent immunosuppressants (eg, azathioprine, cyclosporine).

NOTES

Key: AD = atopic dermatitis; BSA = body surface area; crm = cream; JAK = Janus kinase; MACE = major adverse cardiovascular events; oint = ointment; soln = solution; UVB = ultraviolet B; TCS = topical corticosteroid

 

1 Increased absorption of mid- to higher-potency TCS applied under the wraps may cause hypothalamic-pituitary-adrenal axis suppression.

2 Systemic immunosuppressants (eg, methotrexate, mycophenylate mofetil, azathioprine) have been recommended for severe AD in patients with topical treatment failure.

3 See Topical Steroid Potencies chart for more drug information.

4 For children aged <2yrs with mild to severe disease, off-label use of tacrolimus 0.03% or pimecrolimus 1% can be recommended.

5 Increased risk of serious infections, all-cause mortality, malignancies, MACE, and thrombosis in patients treated with JAK inhibitors for inflammatory conditions.

 

Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.

REFERENCES

Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis. American Academy of Dermatology, Inc. Published: May 07, 2014. http://dx.doi.org/10.1016/j.jaad.2014.03.023

 

Fleming P, Yang YB, Lynde C, O’Neill B, Lee KO. Diagnosis and management of atopic dermatitis for primary care providers. J Am Board Fam Med. 2020; 33 (4); 626-635.

 

Cartron AM, Nguyen TH, Roh YS, Kwatra MM, Kwatra SG. Janus kinase inhibitors for atopic dermatitis: a promising treatment modality. Clin Exp Dermatol. 2021;46(5):820-824. doi:10.1111/ced.14567

(Rev. 6/2022)