Atopic Dermatitis

Background

• Atopic dermatitis is a chronic, relapsing, inflammatory skin disease affecting up to 20% of children and 10% of adults.
• Genetic, dietary, environmental (including active smoking, passive smoking exposure and airborne pollution), and infectious factors may influence the condition and may trigger relapses and exacerbations.
• It is associated with asthma, allergic rhinitis, food allergy, depression and suicidal ideation.

Evaluation

• Diagnosis is based on history and physical findings. Atopic dermatitis often presents as an pruritic, scaly erythematous patches and plaques with characteristic locations and patterns found in particular age groups.
  • In infants, atopic dermatitis most often affects the cheeks, chin, scalp, and extensor surfaces of extremities.
  • In older children and adults, the flexor surfaces, neck, wrists, ankles and nails may be affected.
• Testing is not necessary unless there is concern for superinfection, such as eczema herpeticum, diagnostic uncertainty or if the patient is not responding to therapy.

Management

• Avoid triggers or irritants if clear clinical reaction after exposure to the suspected trigger, and positive allergy testing, if available.
• Daily Bathing and showering should be limited to about 5 minutes. Use bland moisturizers (emollients), including application soon after bathing (Strong recommendation). Avoid fragrances or dyes in moisturizers as they may be irritating.
• Use topical corticosteroids on flaring areas and as maintenance therapy for patients with recurrent flares. (Strong recommendation).
  • Use low potency for mild symptoms, and for eczema on face and neck, consider desonide 0.05% gel, cream or ointment, or foam; or fluocinolone 0.01% cream twice daily.
  • Use medium potency for moderate-to-severe symptoms. Consider betamethasone valerate 0.1% cream or lotion; or fluticasone propionate 0.05% cream twice daily for moderate atopic dermatitis.
  • In patients with recurrent flares, use topical corticosteroids once or twice weekly at sites of prior dermatitis, for proactive, maintenance therapy (Strong recommendation).
• Use topical calcineurin inhibitors (such as tacrolimus 0.1% or pimecrolimus 1% twice daily) for any of the following scenarios (Strong recommendation)
  • recalcitrance to corticosteroids
  • sensitive areas (face, anogenital, skin folds)
  • steroid-induced atrophy
  • long-term uninterrupted topical corticosteroid use
• Consider crisaborole 2% ointment as an alternative topical therapy option for patients ≥ 3 months old with mild-to-moderate atopic dermatitis.
• Consider systemic medication for severe, refractory atopic dermatitis (Weak recommendation).
  • Dupilumab for adults and children ≥ 6 months old with moderate-to-severe atopic dermatitis, not adequately controlled with topical prescription therapies and when other systemic treatment is not advisable. Adverse effects may include keratitis and conjunctivitis.
  • Cyclosporine for chronic, severe cases of atopic dermatitis in adults or children, with monitoring for adverse effects, such as nephrotoxicity and hypertension
  • Azathioprine for adults with chronic, severe cases of atopic dermatitis, if cyclosporine is either not effective or contraindicated. Screen for thiopurine methyltransferase (TPMT) activity before starting azathioprine to reduce risk for bone marrow toxicity
• Do not use long-term systemic glucocorticosteroids (Strong recommendation) and consider them only for short-term use (≤ 1 week) for acute severe exacerbations and as short-term bridge to other systemic steroid-sparing therapy (Weak recommendation).
• Consider phototherapy as maintenance therapy or a second-line treatment in adults after failure of first-line treatment with emollients, topical steroids, and topical calcineurin inhibitors (Weak recommendation).
• Consider bleach baths and intranasal mupirocin for patients who have frequent secondary bacterial infections (Weak recommendation).
• Do not recommend dietary exclusions unless confirmed immunoglobulin E (IgE)-mediated food allergy (Strong recommendation).