Treatment

General

  • Education (no cure, but control disease)

  • Moisturizers (daily, after bathing)
  • Daily bathing / shower (5-10 min, warm water, fragrance-free soap / cleanser)
  • Antimicrobials / antiseptics: bleach baths

Management

  1. Treatment for active eczema (topical corticosteroids with appropriate potency daily until clear +/- taper, +/- antihistamines, +/- antibiotics)
  2. High-level maintenance to recurrent spots (mid-potency topical corticosteroids or topical calcineurin inhibitors 2-3x/week)
  3. Low-level maintenance for all patients (daily moisturizers, avoid triggers)

* Maintenance therapy = avoid relapse, control subclinical inflammation & restore skin barrier

Topical

  • Topical corticosteroids = 1st line (for acute & maintenance treatment; can do wet wrap therapy; side effects: atrophy, acneiform eruption, perioral dermatitis, poor wound healing, telangiectasia, etc.)

  • Calcineurin inhibitors: tacrolimus 0.03% & 0.1% ointment for moderate-severe AD / pimecrolimus 1% cream for mild-moderate (for face & folds mainly; maintenance treatment)
  • Crisaborole 2% ointment (PDE-4 inhibitor; novel therapy for mild-moderate AD & >2yo)

Phototherapy

  • NB-UVB: chronic
  • UVA1: acute & chronic (can also be used in combination with topical corticosteroids)

Systemic

* Children & adults with moderate-severe AD that failed topical treatment

  • Cyclosporine 3-6mg/kg/d
  • Azathioprine 2-3.5mg/kg/d
  • Methotrexate 7.5-25mg/w
  • Mycophenolate mofetil 1-3g/d (adults)
  • Corticosteroids = not recommended
  • Antihistamines (unclear role in AD, routine use not recommended)
  • Antibiotics only if symptoms of infection

Immunotherapy

  • Dupilumab (human monoclonal antibody, targets IL-4Rα subunit of heterodimeric IL-4 & IL-13 receptors; FDA approved for adults with moderate-severe AD; side effects: injection site reaction & conjunctivitis)

Novel therapies

  • Nemolizumab (human monoclonal antibody, targets IL-31 receptor A subunit)
  • Baricitinib (JAK inhibitor)
  • Omalizumab (monoclonal antibody, targets IgE; controversial role in AD therapy)

Presence of allergic diseases

  • Food allergies: Food allergy testing in < 5yo if AD still present albeit maximal treatment or history of immediate allergic reaction after ingestion of specific food allergen. Allergen-IgE assay & skin prick tests with high negative predictive values and low specificity & positive predictive values → clinical judgement important for test results. Elimination diet not recommended, nor food allergen avoidance during pregnancy & lactation
  • Aeroallergens: To consider if AD worse on exposed areas & if development of eczematous plaque with direct skin contact
  • Allergic CD: Patch test if symptoms of allergic CD, distribution atypical for AD, worsening of symptoms or refractory to treatment (common contact allergens: topical medications, fragrance, preservatives, lanolin, propylene glycol, bacitracin, neomycin, corticosteroids)

Prevention

  • Exclusive breastfeeding for first 3-4 months or formula with hydrolyzed milk
  • Use of moisturizers in first 3 weeks of life if family history of atopy to ↓ risk of AD by 30-50% at age of 6-8 months
  • Maternal vitamin D supplementation
  • Insufficient data for pro- or prebiotics