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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.

Conservative Therapy

Elimination of exacerbating factors	Maintaining skin hydration	Controlling pruritus
Avoid trigger factors such as low humidity, overheating of skin Treating stress and anxiety Avoid exposure to solvents and detergents Treat skin infections such as Staphylococcus aureus and herpes simplex	Emollients and moisturizers Thick creams, ointments (eg, petroleum jelly) with low/zero water content Immediately after 5-minute, lukewarm baths BID Bathing practices Warm soaking baths or showers using mild or soap-free cleansers	Conservative Tepid baths Wet dressings (wet wraps) Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor

Medical Therapy

• Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.

Atopic dermatitis

• MIld atopic dermatitis:
  • Topical corticosteroids and emollients - mainstay therapy
    • Adult
      • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
      • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3) crisaborole 2% top.
    • Pediatric
      • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
      • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3): crisaborole 2% top.
• Moderate atopic dermatitis
  • Topical corticosteroids and emollients are the mainstay of therapy
    • Adult
      • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
      • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3) crisaborole 2% top.
  • Pediatric
    • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
    • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14 days
    • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
    • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
    • Alternative regimen (2): pimecrolimus 1% top. q8h
    • Alternative regimen (3) crisaborole 2% top.
• Severe atopic dermatitis
  • Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
    • Adult
      • Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
      • Preferred regimen (2): cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
      • Alternative regimen (1) methotrexatePO
      • Alternative regimen (2): azathioprine PO
      • Alternative regimen (3) mycophenolate mofetil PO
      • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
    • Pediatric
      • Preferred regimen (1):
      • Preferred regimen (2): cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/b q month)
      • Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
      • Alternative regimen (2): azathioprine PO
      • Alternative regimen (3) mycophenolate mofetil PO
      • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
• Severe refractory atopic dermatitis
  • Adult
    • Preferred regimen (1): Intensive topical therapy
      • Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
      • Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
    • Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
    • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
    • Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
    • Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
    • Alternative regimen (5): azathioprine 2 to 3 mg/kg
    • Alternative regimen (6): mycophenolate mofetil 1 to 2 g/day
    • Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
    • Alternative regimen (8) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
  • Pediatric
    • Preferred regimen (1): Intensive topical therapy
      • Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
    • Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
    • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
    • Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
    • Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month

Management of Infection:

• Bacterial infections: (most common bacteria - Staphylococcus. aureus)
  • Clinically infected skin:
    • Mupirocin 2% top. BID for one to two weeks
    • More extensive infection: oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins X two weeks
  • Clinically uninfected skin:
    • liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
• Viral infections:
  • Herpes simplex:
    • Acyclovir 200 or 400 mg PO five times daily
    • Famciclovir 750 mg BID for one day or 1500 mg as a single dose
  • molluscum contagiosum :
    • cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options
• Fungal infections:
  • Dermatophyte infections- topical or oral antifungals

Controlling pruritus:

• Preferred regimen:
  • Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
  • Nonsedatives: fexofenadine, cetirizine or loratadine
• Alternative regimen:
  • Topical doxepin
  • Topical calcineurin inhibitors
    •  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%

Chronic inflammatory skin diseases

• Contact (allergic, irritant)
• Seborrhoeic dermatitis
  • onset during the 1st days or weeks of life, absence of pruritus, and presence of greasy scaling on a yellow-red base
  • Involvement of the top of the scalp (cradle cap), axilla, and diaper area makes it more likely the patient has seborrheic dermatitis, vs excoriated dermatitis involving the extensor surfaces, face, and trunk favour AE.
• Psoriasis
• Lichen simplex chronicus

Infectious agents

• Candida
• Dermatophytes
• Herpes simplex
• Staphylococcus aureus
• Sarcoptes scabiei
  • highly pruritic, erythematous papular lesions. In most cases, the typical burrows can be found on the flexor wrists, finger webs and genitalia. Similar symptoms in other family members
• HIV-associated dermatitis

Immunologic disorders

• Dermatitis herpetiformis
• Pemphigus foliaceus
• Graft-versus-host disease
• Dermatomyositis

Malignant Diseases

• Cutaneous T-cell lymphoma (mycosis fungoides, S´ezary syndrome)
• Histiocytosis X (Letterer-Siwe disease)

Congenital disorders

• Netherton’s syndrome
• Dubowitz syndrome
• Erythrokeratodermia variabilis

Immunodeficiencies

• Wiskott-Aldrich syndrome (immunodeficiency with thrombocytopenia and eczema)
• Thymic hypoplasia (DiGeorge syndrome)
• Hyper-IgE syndrome
• Severe combined immunodeficiency (SCID)
• Ataxia teleangiectasia

Metabolic Diseases

• Phenylketonuria
• Tyrosinemia
• Histidinemia
• Zinc deficiency
• Pyridoxine (vitamin B6) and niacin deficiency
• Multiple carboxylase deficiency

• Nonallergic reaction to medication
  • Infliximab