Highlights & Basics
- Atopic dermatitis commonly presents with dry, itchy skin.
- Typically there is erythema, scaling, vesicles, or lichenification in skin flexures.
- Diagnosis is primarily clinical.
- First-line treatment is with emollients and topical corticosteroids.
- Other options that may be used in patients unresponsive to first-line therapy include topical calcineurin inhibitors, phototherapy, biologic agents, or immunomodulatory agents.
Quick Reference
History & Exam
Key Factors
pruritus
xerosis (dry skin)
sites of skin involvement
Other Factors
erythema
scaling
vesicles
papules
keratosis pilaris
excoriations
lichenification
hypopigmentation
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Other Tests to consider
IgE levels
skin-prick testing
oral food challenge
trial elimination diet
patch testing
skin biopsy
Treatment Options
acute
acute flare
emollients
intermittent topical corticosteroids
topical or oral antibiotic therapy
systemic immunosuppressive agent
emollients
intermittent topical corticosteroids
topical or oral antibiotic therapy
Definition
Classifications
Classification by age: infantile, childhood, and adult phases
- Typically lasts from shortly after birth to 2 years of age
- Often begins with dermatitis on the cheeks, forehead, and scalp with significant involvement of extensor surfaces of the limbs
- Commonly a prominent vesicular component with edema, weeping, and crusting
- Facial atopic dermatitis may be worse while infants are teething and with trials of new foods
- Extensor surface involvement may be related to the onset of crawling.
- Lasts from 2 years of age until puberty; children with already persistent disease, later onset, and/or more severe disease have increased persistence
- Affected areas are typically less vesicular, with papules and plaques becoming more lichenified due to constant scratching
- Children typically have involvement of the flexural skin, with predominance in the antecubital and popliteal fossa, wrists, hands, ankles, and feet
- When facial involvement is present, it is typically confined to perioral and periorbital skin.Image
- Extends from puberty through adulthood
- Thickened, dry skin and lichenified plaques are typical; flexural skin, the upper back and arms, as well as the dorsal surfaces of the hands and feet, are often affected
- Dyshidrotic changes may be present on the palms and soles.Images
Eczema Area and Severity Index
Scoring of Atopic Dermatitis
Vignette
Common Vignette
Other Presentations
Epidemiology
Etiology
- Irritants such as soaps and detergents (including shampoos, bubble baths)
- Skin infections (Staphylococcus aureus infection is a common cause of atopic dermatitis exacerbation)
- Contact allergens
- Food allergens (cows' milk, egg, nuts)
- Inhalant allergens (dust mite)
- Vitamin E deficiency
- Hard domestic water supply (high calcium carbonate).
Pathophysiology
Images
Acute atopic dermatitis in the antecubital fossa of a 9-year-old girl
Lichenification of the popliteal fossa in a child with atopic dermatitis
Chronic dermatitis affecting the palm of a 64-year-old man
Hypopigmentation on the dorsal aspect of the hand in a 12-year-old girl with atopic dermatitis
Papules, lichenification, and hypopigmentation in a child with chronic atopic dermatitis
Hypopigmentation on the flexural skin of the ankles in the same patient
Acute atopic dermatitis on the face of an infant
Diagnostic Approach
History
- Time of onset, pattern, and severity of the atopic dermatitis
- Response to previous and current treatment
- Possible trigger factors (irritant and allergic)
- The impact of the atopic dermatitis on children and their parents or caregivers
- Dietary history including any dietary manipulations
- Growth and development
- Personal and family history of atopic disease.
Clinical evaluation
- Extensor surfaces, cheeks, and forehead are preferentially affected in infants. Groin and diaper area are usually spared.
- In older children and adults, skin flexures are most commonly affected, with hyperpigmentation or hypopigmentation and excoriations from constant scratching.
- More well-demarcated lesions and increased scaling and lichenification are more common in Asian patients
- Patients of African descent are less likely to develop flexural dermatitis, but rather present with extensor involvement as a more prominent feature
- Discoid or follicular patterns may be more common in Asian, black Caribbean, and black African children.
Consideration of coexistent allergy
- with seasonal flares of atopic dermatitis
- with atopic dermatitis associated with asthma or allergic rhinitis
- ages 3 years or over with atopic dermatitis on the face, particularly around the eyes.
Risk Factors
History & Exam
Tests
Differential Diagnosis
Seborrheic dermatitis
Differentiating Signs/Symptoms
- Characteristic greasy scale that is not pruritic. Often affects cheeks, scalp, extremities, and trunk. Unlike atopic dermatitis, the diaper area is often affected.
Differentiating Tests
- Clinical exam is the best tool to differentiate between these lesions.
Irritant contact dermatitis
Differentiating Signs/Symptoms
- Common in diaper area, face, and extensor surfaces in children; results from exposure to irritating substances. Typically less pruritic than atopic dermatitis.
Differentiating Tests
- Elimination of irritants will result in clinical improvement.
- Patch testing may be positive for relevant irritants.
- May be limited role for skin biopsy (e.g., patch tests are negative, chronic disease, uncertain diagnosis), which can identify whether contact dermatitis is present. Skin biopsy does not distinguish irritant contact dermatitis from allergic contact dermatitis.
Allergic contact dermatitis
Differentiating Signs/Symptoms
- Well-circumscribed erythematous lesions, often with spongiotic papules, vesicles, and crusting. Lesions are usually pruritic and asymmetric (unlike those associated with atopic dermatitis, which are typically symmetric). Eruptions are due to contact with specific allergen, and removal of offending agent results in resolution of symptoms.
Differentiating Tests
- Elimination of allergic stimuli results in resolution of dermatitis.
- Patch testing may be positive for relevant allergen.
- May be limited role for skin biopsy (e.g., patch tests are negative, chronic disease, uncertain diagnosis), which can identify whether contact dermatitis is present. Skin biopsy does not distinguish irritant contact dermatitis from allergic contact dermatitis.
Scabies
Differentiating Signs/Symptoms
- Severe pruritus, particularly at night. In addition to papules or vesicles, burrows may be evident and will help to make the diagnosis. The wrists, ankles, palms, soles, interdigital spaces, axillae, waist, and groin are the most commonly affected sites. Patients will often report similar symptoms in family members or other close contacts.[9]
Differentiating Tests
- Microscopy may reveal mites, eggs, or scybala (mite feces).
Psoriasis
Differentiating Signs/Symptoms
- Well-circumscribed, erythematous lesions with silver scale that show a predilection for extensor surfaces, particularly elbows and knees.
- The nail pitting seen in psoriasis has smaller pits and is more common than that seen in patients with atopic dermatitis.
Differentiating Tests
- This is usually a clinical diagnosis. No laboratory testing is typically necessary to distinguish between atopic dermatitis and psoriasis.
- If the diagnosis is uncertain, there may be a limited role for skin biopsy, which may not always reveal the classic features of psoriasis.
Mycosis fungoides
Differentiating Signs/Symptoms
- The initial stages of mycosis fungoides (cutaneous T-cell lymphoma) may look similar to atopic dermatitis. Erythematous plaques in random distribution are common and scale is often present. As opposed to patients with atopic dermatitis, patients with mycosis fungoides tend to be older at the time of diagnosis, with an average age ≥50 years.[64]
Differentiating Tests
- Skin biopsy is necessary to make the diagnosis of mycosis fungoides.
- Additional studies that encompass cell flow cytometry may be used to confirm the diagnosis.
Criteria
- Pruritus
- Dermatitis affecting flexural surfaces in adults and the face and extensors in infants
- Chronic or relapsing dermatitis
- Personal or family history of cutaneous or respiratory atopy.
- Facial features: facial pallor, facial erythema, hypopigmented patches, infraorbital darkening, infraorbital folds (Dennie-Morgan folds), cheilitis, recurrent conjunctivitis, anterior neck folds.
- Triggers: foods, emotional factors, environmental factors, skin irritants.
- Complications: susceptibility to cutaneous infections, impaired cell-mediated immunity, immediate skin-test reactivity, elevated IgE, keratoconus, anterior subcapsular cataracts.
- Other: early age of onset, dry skin, ichthyosis, hyperlinear palms, keratosis pilaris, hand and foot dermatitis, nipple eczema, white dermatographism, perifollicular accentuation.
- Face or neck
- Trunk
- Flexor or extensor aspects of arms or legs.
- Antecubital or popliteal fossae
- Wrists or ankles
- Face or neck
- Hands, arms, or legs
- Body.
- History of a flexural involvement (antecubital or popliteal fossa, front of ankles, wrists or neck)
- Visible flexural dermatitis
- Personal history of asthma or hay fever (or history of atopic disease in parents or siblings if the patient is younger than 4 years of age)
- History of a generally dry skin in the last year
- Onset under the age of 2.
Treatment Approach
Optimizing treatment
- Atopic dermatitis is often not viewed as a chronic condition, which impairs effective management
- The significant psychosocial impact of atopic dermatitis is not acknowledged by others
- Hesitancy on the part of healthcare providers is communicated to patients with regards to treating atopic dermatitis
- There is insufficient information and advice about treatments available.
Emollients for all patients
- Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days).
- Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled.
Topical corticosteroids
- Mild potency for mild atopic dermatitis
- Moderate potency for moderate atopic dermatitis
- Potent for severe atopic dermatitis
- Face and neck: use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares
- Flares in vulnerable sites (e.g., axillae and groin): moderate or potent preparations for short periods only (7-14 days)
- Very potent preparations should not be used for children without specialist advice.
- Low-potency: hydrocortisone, desonide[95]
- Mid-potency: fluticasone,triamcinolone, fluocinolone
- High-potency: mometasone, betamethasone, desoximetasone
- Very high-potency: clobetasol, halobetasol, diflorasone.
Topical calcineurin inhibitors
- Topical tacrolimus is recommended as second-line treatment of moderate to severe atopic dermatitis in adults and children ages 2 years and older. (Only the 0.03% strength is licensed in children.)
- Topical pimecrolimus is recommended as second-line treatment of moderate atopic dermatitis on the face and neck in children ages 2-16 years.
Topical crisaborole
Recurrent flares
Phototherapy (UV therapy)
Systemic therapy
- The patient has moderate to severe atopic dermatitis that has not responded to topical therapy and phototherapy (disease severity measured using a score such as the Eczema Area and Severity Index [EASI])
- Adequate education has been provided, including discussion of possible steroid phobia
- Infection has been excluded and allergy has been considered including, if indicated, patch testing or referral to allergy services.
- Its use in atopic dermatitis is off-label; survey data suggest that it may be widely used.[115]
- Assess thiopurine methyltransferase (TPMT) activity before initiating therapy, and reduce the dose in patients with reduced TPMT activity. Consider TPMT testing in patients with abnormal complete blood counts that persist despite dose reduction of azathioprine.
- Adverse effects include gastrointestinal disturbances and abnormalities in liver enzymes and blood counts (e.g., lymphocytopenia).
- May be more effective for short-term (up to 16 weeks) treatment of adult patients with atopic dermatitis than methotrexate and azathioprine.[116]
- Short courses of cyclosporine (2 weeks) may be beneficial in controlling particularly treatment-resistant disease, and allow for the introduction of maintenance regimens.
- Use in atopic dermatitis is off-label.
- Cyclosporine is not effective topically (due to its high molecular weight).
- Observational data suggest clinical improvement of moderate to severe atopic dermatitis in patients treated with subcutaneous methotrexate.[122]
- Use in atopic dermatitis is off-label.
- Anti-inflammatory effects make methotrexate a useful second-line agent for the treatment of atopic dermatitis.
- Compared with standard of care, there is high-certainty evidence that dupilumab decreases Scoring of Atopic Dermatitis (SCORAD) value, EASI, and pruritus and improves quality of life in adult patients with atopic dermatitis.[111] Efficacy outcomes are similar in adolescents.
- One Cochrane network analysis found that dupilumab is the most effective biologic treatment for atopic dermatitis.[127] Evidence for most standard systemic agents (e.g., azathioprine, methotrexate) was weak.
- Adverse effects include injection-site reactions, ocular adverse effects (e.g., conjunctivitis, blepharitis), and oral herpes.[128]
- Can be used with or without topical corticosteroids.
- Approved for the treatment of moderate to severe atopic dermatitis in adults and children ≥6 months of age whose disease is not adequately controlled with topical prescription therapies (or when those therapies are not advisable).
- Used off-label in the treatment of both adult and pediatric patients with treatment-refractory atopic dermatitis.[79]
- One systematic review of patients with severe atopic dermatitis (n=140; average number of failed agents 3.5) reported partial or full remission in 76% of patients with atopic dermatitis.[129]
- Adverse effects include headaches, gastrointestinal complaints, and fatigue.
- Prolonged treatment (≥1 year) is associated with increased risk of herpes infections.[129]
Antibiotic therapy
Therapies with no evidence
Written action plans
Treatment Options
acute flare
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[83] [85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
intermittent topical corticosteroids
Primary Options
- hydrocortisone topical
(0.2 to 2.5%) apply sparingly to the affected area(s) twice daily
- hydrocortisone topical
- desonide topical
(0.05%) apply sparingly to the affected area(s) twice to three times daily
- desonide topical
- fluticasone propionate topical
(0.05%) apply sparingly to the affected area(s) twice daily
- fluticasone propionate topical
Secondary Options
- triamcinolone topical
(0.1%) apply sparingly to the affected area(s) once to four times daily
- triamcinolone topical
- fluocinolone topical
(0.025%) apply sparingly to the affected area(s) twice to four times daily
- fluocinolone topical
- mometasone topical
(0.1%) apply sparingly to the affected area(s) once daily
- mometasone topical
- betamethasone dipropionate topical
(0.05%) apply sparingly to the affected area(s) once or twice daily
- betamethasone dipropionate topical
- desoximetasone topical
(0.05 to 0.25%) apply sparingly to the affected area(s) twice daily
- desoximetasone topical
Tertiary Options
- clobetasol topical
(0.05%) apply sparingly to the affected area(s) twice daily, maximum 2 weeks treatment
- clobetasol topical
- halobetasol topical
(0.05%) apply sparingly to the affected area(s) once or twice daily, maximum 50 g/week
- halobetasol topical
- diflorasone topical
(0.05%) apply sparingly to the affected area(s) once to four times daily, short-term use only
- diflorasone topical
Comments
- Corticosteroids reduce inflammation and pruritus. They may be used in patients not controlled with emollients alone. Intermittent use on affected areas may be sufficient to control symptoms.
- Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[83] Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[86] Moderate-to-high-potency topical corticosteroids may be more effective than low-potency topical corticosteroids for patients with moderate to severe atopic dermatitis.[87] If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.
- While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat atopic dermatitis flares.[87]
- In the UK, topical corticosteroids should be applied once or twice daily; the potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45] Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very potent preparations should not be used for children without specialist advice.
- A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected in children with atopic dermatitis.[45] Once the flare has settled, treating problem areas with topical corticosteroids for 2 consecutive days a week to prevent further flares could be considered for children who experience frequent flares (2 or 3 per month).[45] [87]
- Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize adverse effects.
- Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible.
- Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[137]
- Options include:[94]
- Low-potency: hydrocortisone, desonide[95]
- Mid-potency: fluticasone, triamcinolone, fluocinolone
- High-potency: mometasone, betamethasone, desoximetasone
- Very high-potency: clobetasol, halobetasol, diflorasone.
topical or oral antibiotic therapy
Comments
- Antibiotics are recommended in patients with evidence of cutaneous infection or suspected colonization.
systemic immunosuppressive agent
Primary Options
- prednisone
children: consult specialist for guidance on dose; adults: 5-60 mg/day orally
- prednisone
- cyclosporine modified
children: consult specialist for guidance on dose; adults: 2.5 to 5 mg/kg/day orally given in 2 divided doses
- cyclosporine modified
Comments
- In an acute severe flare, a short course of an oral corticosteroid or cyclosporine may be required due to their rapid onset of action. The patient may be switched to another agent once disease is controlled.
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
intermittent topical corticosteroids
Primary Options
- hydrocortisone topical
(0.2 to 2.5%) apply sparingly to the affected area(s) twice daily
- hydrocortisone topical
- desonide topical
(0.05%) apply sparingly to the affected area(s) twice to three times daily
- desonide topical
- fluticasone propionate topical
(0.05%) apply sparingly to the affected area(s) twice daily
- fluticasone propionate topical
Secondary Options
- triamcinolone topical
(0.1%) apply sparingly to the affected area(s) once to four times daily
- triamcinolone topical
- fluocinolone topical
(0.025%) apply sparingly to the affected area(s) twice to four times daily
- fluocinolone topical
- mometasone topical
(0.1%) apply sparingly to the affected area(s) once daily
- mometasone topical
- betamethasone dipropionate topical
(0.05%) apply sparingly to the affected area(s) once or twice daily
- betamethasone dipropionate topical
- desoximetasone topical
(0.05 to 0.25%) apply sparingly to the affected area(s) twice daily
- desoximetasone topical
Tertiary Options
- clobetasol topical
(0.05%) apply sparingly to the affected area(s) twice daily, maximum 2 weeks treatment
- clobetasol topical
- halobetasol topical
(0.05%) apply sparingly to the affected area(s) once or twice daily, maximum 50 g/week
- halobetasol topical
- diflorasone topical
(0.05%) apply sparingly to the affected area(s) once to four times daily, short-term use only
- diflorasone topical
Comments
- Corticosteroids reduce inflammation and pruritus. They may be used in patients not controlled with emollients alone. Intermittent use on affected areas may be sufficient to control symptoms.
- Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[83] Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[86] Moderate-to-high-potency topical corticosteroids may be more effective than low-potency topical corticosteroids for patients with moderate to severe atopic dermatitis.[87] If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.
- While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat atopic dermatitis flares.[87]
- In the UK, topical corticosteroids should be applied once or twice daily; the potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45] Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very potent preparations should not be used for children without specialist advice.
- A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected in children with atopic dermatitis.[45] Once the flare has settled, treating problem areas with topical corticosteroids for 2 consecutive days a week to prevent further flares could be considered for children who experience frequent flares (2 or 3 per month).[45] [87]
- Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize adverse effects.
- Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible.
- Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[137]
- Options include:[94]
- Low-potency: hydrocortisone, desonide[95]
- Mid-potency: fluticasone, triamcinolone, fluocinolone
- High-potency: mometasone, betamethasone, desoximetasone
- Very high-potency: clobetasol, halobetasol, diflorasone.
topical or oral antibiotic therapy
Comments
- Antibiotics are recommended in patients with evidence of cutaneous infection or suspected colonization.
chronic or relapsing disease (nonrefractory)
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
continuous use of low- to mid-potency topical corticosteroid
Primary Options
- hydrocortisone topical
(0.5 to 2.5%) apply sparingly to the affected area(s) twice daily
- hydrocortisone topical
Secondary Options
- desonide topical
(0.05%) apply sparingly to the affected area(s) twice to three times daily
- desonide topical
Tertiary Options
- fluticasone propionate topical
(0.05%) apply sparingly to the affected area(s) twice daily
- fluticasone propionate topical
- triamcinolone topical
(0.1%) apply sparingly to the affected area(s) once to four times daily
- triamcinolone topical
- fluocinolone topical
(0.025%) apply sparingly to the affected area(s) twice to four times daily
- fluocinolone topical
Comments
- Corticosteroids reduce inflammation and pruritus. They may be used in patients not controlled with emollients alone. Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize adverse effects.
- Topical corticosteroids may be used in combination with emollients.[83] Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In the UK, topical corticosteroids should be applied once or twice daily; the potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45] Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days).
- A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected in children with atopic dermatitis.[45] Once the flare has settled, treating problem areas with topical corticosteroids for 2 consecutive days a week to prevent further flares could be considered for children who experience frequent flares (2 or 3 per month).[45] [87]
- Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible.
- Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing. While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily dosing by the Food and Drug Administration.
- Options include:[94]
- Low-potency: hydrocortisone, desonide[95]
- Mid-potency: fluticasone, triamcinolone, fluocinolone.
topical calcineurin inhibitor
Primary Options
- pimecrolimus topical
(1%) children >2 years of age and adults: apply to the affected area(s) twice daily
- pimecrolimus topical
Secondary Options
- tacrolimus topical
(0.03%) children >2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) adults: apply to the affected area(s) twice daily
- tacrolimus topical
Comments
- If there is a need for daily topical corticosteroids to maintain control of atopic dermatitis (and particularly if there is facial atopic dermatitis with eyelid involvement), a topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) may be considered, either as monotherapy or in combination with a topical corticosteroid.[83]
- Topical calcineurin inhibitors should be used by physicians who are experienced in treating atopic dermatitis. Pimecrolimus 1% and tacrolimus 0.03% can be used in patients ages 2 years or older, and tacrolimus 0.1% can be used in patients ages 16 years or older.
- In the UK, topical tacrolimus is recommended as second-line treatment of moderate to severe atopic dermatitis in adults and children ages 2 years and older (only the 0.03% strength is licensed in children); topical pimecrolimus is recommended as second-line treatment of moderate atopic dermatitis on the face and neck in children ages 2-16 years. Both treatments are only considered for patients who are refractory to topical corticosteroids or where there is a serious risk of adverse effects from further topical corticosteroid use, such as irreversible skin atrophy.[45] For patients with facial atopic dermatitis that requires long-term treatment with mild topical corticosteroids, stepping up treatment to a topical calcineurin inhibitor may be considered.
- In one meta-analysis, calcineurin inhibitors were found to be the most effective topical agent in lessening pruritus associated with atopic dermatitis.[96] Another systematic review of 20 trials reported that tacrolimus (0.1%) was more effective than pimecrolimus, tacrolimus (0.03%), and low-potency corticosteroids for the treatment of atopic dermatitis.[97] In addition, tacrolimus (0.03%) was found to be superior to mild corticosteroids and pimecrolimus.[97]
- There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been established, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.
- A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[98] The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[98] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or topical pimecrolimus significantly increased the risk of lymphoma.[99] Subgroup analyses showed that both topical tacrolimus and topical pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[99]
topical crisaborole
Primary Options
- crisaborole topical
(2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily
- crisaborole topical
Comments
- Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, can be used for the management of mild to moderate atopic dermatitis in patients ages 3 months and older.
refractory chronic or relapsing disease
resistant to topical corticosteroids and topical calcineurin inhibitors
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
continuous use of high-potency topical corticosteroid
Primary Options
- mometasone topical
(0.1%) apply sparingly to the affected area(s) once daily
- mometasone topical
- betamethasone dipropionate topical
(0.05%) apply sparingly to the affected area(s) once or twice daily
- betamethasone dipropionate topical
- desoximetasone topical
(0.05 to 0.25%) apply sparingly to the affected area(s) twice daily
- desoximetasone topical
Secondary Options
- clobetasol topical
(0.05%) apply sparingly to the affected area(s) twice daily, maximum 2 weeks treatment
- clobetasol topical
- halobetasol topical
(0.05%) apply sparingly to the affected area(s) once or twice daily, maximum 50 g/week
- halobetasol topical
- diflorasone topical
(0.05%) apply sparingly to the affected area(s) once to four times daily, short-term use only
- diflorasone topical
Comments
- Topical corticosteroids reduce inflammation and pruritus, and are often used in short bursts for flares of atopic dermatitis.
- Topical corticosteroids may be used in combination with emollients.[83] Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize adverse effects.
- In the UK, topical corticosteroids should be applied once or twice daily; the potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45] Potent preparations for severe atopic dermatitis; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very potent preparations should not be used for children without specialist advice.
- A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected in children with atopic dermatitis.[45] Once the flare has settled, treating problem areas with topical corticosteroids for 2 consecutive days a week to prevent further flares could be considered for children who experience frequent flares (2 or 3 per month).[45] [87]
- Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible.
- Percentages included in the name of the corticosteroid do not correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.
resistant to high-potency topical corticosteroids
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[83] [85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
- In the UK, occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]
- Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days); whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled.[45]
- The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]
UV light therapy
Comments
- Ultraviolet (UV) phototherapy is frequently used in the management of moderate to severe generalized atopic dermatitis. It exerts beneficial effects through immunosuppressive, immunomodulating, and anti‐inflammatory actions.
- Several forms of phototherapy are available for disease and symptom control, but comparative studies are limited, with low-certainty conclusions.[107] With respect to efficacy, US guidelines do not differentiate between the different types of phototherapy; choice is informed by factors including availability, patient skin type, and patient use of photosensitizing medications.[79] UK and European guidelines recommend narrow-band UVB or UVA1 as first-line for generalized atopic dermatitis; UK guidance prefers topical/oral psoralen plus UVA (PUVA) for localized palmoplantar disease.EDF: European guideline (EuroGuiDerm) on atopic eczema
- Patients are treated two to three times weekly until clearance is achieved, at which point spacing between treatments is progressively increased, and treatment is often stopped altogether.
- Phototherapy is rarely used in children; its use is dependent upon feasibility and psychosocial factors (e.g., intimidating lamps/machines, caregiver concerns).[79] In the UK, phototherapy should only be considered for children with severe atopic dermatitis when other management options have failed, or are inappropriate.[45] A small proportion of patients will experience a flare in atopic dermatitis with both sunlight and phototherapy. Common phototherapy adverse effects include: actinic damage, local erythema and tenderness, pruritus, burning, and stinging.[79]
- Refer to local protocol for UV administration.
resistant to topical therapy and UV light therapy
emollients
Comments
- Emollients are an essential component of atopic dermatitis therapy because they improve skin barrier function by rehydrating the skin.[78] [83] Emollients may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]
- Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.
- By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).EDF: European guideline (EuroGuiDerm) on atopic eczema
- Emollients may be sufficient to manage symptoms in a few patients. In all other patients, emollients are used in combination with other therapeutic agents. One Cochrane review found that emollients combined with an active treatment improves results compared with active treatment alone.[78]
- Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.EDF: European guideline (EuroGuiDerm) on atopic eczema
- In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[83] [85] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[83]
- In the UK, occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]
- Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days); whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled.[45]
- The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]
systemic immunosuppressive agent
Primary Options
- cyclosporine modified
children: consult specialist for guidance on dose; adults: 2.5 to 5 mg/kg/day orally given in 2 divided doses
- cyclosporine modified
Secondary Options
- azathioprine
children: consult specialist for guidance on dose; adults: 1 to 2.5 mg/kg orally once daily
- azathioprine
- methotrexate
children: consult specialist for guidance on dose; adults: 7.5 to 25 mg orally/subcutaneously once weekly on the same day of each week
- methotrexate
- mycophenolate mofetil
children and adults: consult specialist for guidance on dose
- mycophenolate mofetil
Tertiary Options
- dupilumab
children ≥6 months to 5 years of age and body weight 5-14 kg: 200 mg subcutaneously every 4 weeks; children ≥6 months to 5 years of age and body weight 15-29 kg: 300 mg subcutaneously every 4 weeks; children ≥6 years of age and body weight 15-29 kg: 600 mg subcutaneously initially, followed by 300 mg every 4 weeks; children ≥6 years of age and body weight 30-59 kg: 400 mg subcutaneously initially, followed by 200 mg every 2 weeks; children ≥6 years of age and body weight ≥60 kg and adults: 600 mg subcutaneously initially, followed by 300 mg every 2 weeks
- dupilumab
Comments
- The International Eczema Council advises starting systemic therapy if: the patient has moderate to severe atopic dermatitis that has not responded to topical therapy and phototherapy (disease severity measured using a score such as the Eczema Area and Severity Index); adequate education has been provided, including discussion of possible steroid phobia; infection has been excluded and allergy has been considered including, if indicated, patch testing or referral to allergy services.[110]
- Standard systemic agents used for atopic dermatitis with reported efficacy in moderate to severe disease include azathioprine, cyclosporine, and methotrexate.[110]
- Dupilumab, a monoclonal antibody, compares favorably to standard of care for uncontrolled moderate to severe atopic dermatitis.[111]
- Mycophenolate has been used in patients with refractory atopic dermatitis, and those with adverse effects to initial systemic agents.
- Choice of therapy is determined by onset and severity of symptoms (e.g., oral cyclosporine may be used in an acute, severe flare due to rapid onset of action and the patient may then be switched to another agent when disease has been controlled), sex (methotrexate may be avoided in women of childbearing age planning to conceive), comorbidities (cyclosporine is avoided in renal impairment, methotrexate is avoided if liver fibrosis is present or in renal impairment), and patient choice.
- Systemic therapies must be used under the guidance of a specialist.[112] Include assessment of severity and quality of life while considering the individual's general health status, psychological needs, and personal attitudes toward systemic therapies when deciding to start systemic medication.[110]
Emerging Tx
Tralokinumab
Oral Janus kinase (JAK) inhibitors
Topical JAK inhibitors
Lebrikizumab
Nemolizumab
Omalizumab
Orismilast
Retinoids
Dietary alterations
Prevention
Primary Prevention
Follow-Up Overview
Prognosis
Monitoring
Complications
Citations
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Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33.[Abstract][Full Text]
Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb;70(2):338-51.[Abstract][Full Text]
Sidbury R, Davis DM, Cohen DE, et al; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327-49.[Abstract][Full Text]
Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jan 11:S0190-9622(23)00004-X. [Abstract][Full Text]
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Key Articles
Other Online Resources
Referenced Articles
Guidelines
Diagnostic
Summary
Reviews current guideline-based management of children with atopic dermatitis.Published by
American Academy of Allergy, Asthma and Immunology
Published
2022
Summary
Addresses the association between atopic dermatitis and other medical conditions.Published by
American Academy of Dermatology
Published
2022
Summary
Addresses diagnosis and assessment of atopic dermatitis.Published by
American Academy of Dermatology
Published
2014
Summary
Diagnosis of atopic dermatitis based on a constellation of clinical features.Published by
American Academy of Allergy, Asthma and Immunology
Published
2013
Summary
Provides guidance on diagnosis of atopic eczema.Published by
National Institute for Health and Care Excellence
Published
2023
Treatment
Summary
Reviews current guideline-based management of children with atopic dermatitis.Published by
American Academy of Allergy, Asthma and Immunology
Published
2022
Summary
Treatment of atopic dermatitis with nonpharmacologic interventions and pharmacologic topical therapies are reviewed.Published by
American Academy of Dermatology
Published
2023
Summary
Treatment of atopic dermatitis with phototherapy and systemic immunomodulators, antimicrobials, and antihistamines are reviewed.Published by
American Academy of Dermatology
Published
2014
Summary
Treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed.Published by
American Academy of Dermatology
Published
2014
Summary
Practice parameter recommendations regarding the management of atopic dermatitis.Published by
American Academy of Allergy, Asthma and Immunology
Published
2013
Summary
Consensus-based recommendations on systemic treatment for atopic dermatitis.Published by
European Dermatology Forum
Published
2022
Summary
Consensus-based guidance on the management of atopic dermatitis.Published by
European Dermatology Forum
Published
2022
Summary
Addresses the management of atopic dermatitis in children.Published by
National Institute for Health and Care Excellence
Published
2023