Atopic Dermatitis (Eczema)

Publication Date: December 17, 2023
Last Updated: December 17, 2024

Diagnosis

Recommendation 1

Clinicians managing all severities of atopic dermatitis should, before issuing any new therapy,
1. ensure the correct diagnosis and identify complicating diagnoses,
2. provide education, for instance an information guide about the disease and an action plan,
3. address trigger avoidance,
4. ensure proper medication use/adherence, and
5. encourage application of a bland moisturizer titrated to symptomatic benefit (at least once, often multiple times, per day). (GPS, )
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Topical Treatments

Recommendation 2

In patients with atopic dermatitis, the JTF panel suggests using a standard, bland (free of fragrance and other potential contact allergens) over-the-counter moisturizer over a prescription moisturizer medical device (e.g., Atopiclair, Eletone, Epiceram, MimyX, Neosalus, Zenieva, and PruMyx). (L, C)
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Recommendation 3

In patients with uncontrolled atopic dermatitis refractory to moisturization alone, the JTF panel recommends addition of a topical corticosteroid over no topical corticosteroid. (H, S)
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Recommendation 4

In patients aged 3 months or older with uncontrolled atopic dermatitis refractory to moisturization alone, the JTF panel recommends addition of a topical calcineurin inhibitor (pimecrolimus, tacrolimus) over no added topical calcineurin inhibitor. (H, S)
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Recommendation 5

In patients with localized uncontrolled atopic dermatitis refractory to mid-high–potency topical treatment (US classes 2–5 or tacrolimus), the JTF panel suggests addition of a time and body area-limited (e.g., 4–7 days; minimum 1 hour to maximum overnight, once per day) trial of occlusive low-mid–potency topical corticosteroid (US classes 3–7) therapy over continued standard topical therapy alone. (VL, C)
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Recommendation 6

In patients with uncontrolled atopic dermatitis using mid-to high potency topical treatments (tacrolimus, topical corticosteroid US classes 1–5), the JTF panel suggests applying the medication once per day over twice per day. (M, C)
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Recommendation 7

In patients with mild-moderate atopic dermatitis refractory to moisturization alone, the JTF panel suggests adding topical crisaborole 2% ointment over usual care alone. (H, C)
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Recommendation 8

In adolescent and adult patients with mild-moderate atopic dermatitis refractory to moisturization alone, the JTF panel suggests against adding topical ruxolitinib over continued usual care alone. (L, C)
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Recommendation 9

In patients with uncontrolled atopic dermatitis and no serious bacterial skin infection (i.e., without severe weeping, crusting, pustules, or painful skin or other signs of extensive infection or systemic illness), the JTF panel suggests against adding topical antimicrobials to standard topical treatments. (VL, C)
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Recommendation 10

In patients with atopic dermatitis and a relapsing course, the JTF panel recommends use of proactive therapy to areas that frequently flare with a topical calcineurin inhibitor or mid-potency topical corticosteroid (US classes 3–5), over applying topical treatments only in reaction to flares. (M, S)
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Bleach Baths

Recommendation 11

In patients with moderate-severe atopic dermatitis, the JTF panel suggests, in addition to topical therapy, dilute bleach baths over usual (no dilute bleach-based) baths. (L, C)
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Recommendation 12

In patients with mild atopic dermatitis, the JTF panel suggests against adding dilute bleach baths to topical therapy (no dilute-bleach based) baths. (L, C)
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Elimination Diets (With or Without Skin Testing)

Recommendation 13

In patients with atopic dermatitis, the JTF panel suggests against the use of elimination diets compared with an unrestricted diet. (L, C)
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Allergen Immunotherapy (Subcutaneous and Sublingual)

Recommendation 14

In patients with moderate-severe atopic dermatitis refractory, intolerant, or unable to use mid-potency topical treatment, the JTF panel suggests adding allergen immunotherapy to standard topical treatment over not adding. (M, C)
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Recommendation 15

In patients with mild atopic dermatitis, the JTF panel suggests against adding allergen immunotherapy to standard topical treatment. (M, C)
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Systemic Treatments

Recommendation 16

In patients 6 months of age or older with moderate-severe AD refractory, intolerant, or unable to use mid-potency or greater topical treatment, the JTF panel recommends adding dupilumab over continued standard topical treatment without dupilumab. (H, S)
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Recommendation 17

In patients 12 years of age or older with moderate-severe AD refractory, intolerant, or unable to use midpotency topical treatment, the JTF panel recommends adding tralokinumab over continued topical treatment without tralokinumab. (H, S)
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Recommendation 18

In adults and adolescents with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the panel suggests replacing the systemic treatment with one of the following oral JAK inhibitors (alphabetical order: abrocitinib 100–200 mg [age 12 years or above], baricitinib 2–4 mg [age 18 years or above], upadacitinib 15–30 mg [age 12 years or above]) over not using one of these JAK inhibitors. (L, C)

Note: See Recommendation 19 regarding baricitinib 1 mg dose.

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Recommendation 19

In adults and adolescents with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of one of the biologics (dupilumab or tralokinumab) recommended above, the panel recommends against using baricitinib 1 mg daily. (L, S)
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Recommendation 20

In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended above, the panel suggests against using azathioprine. (L, C)
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Recommendation 21

In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the JTF panel suggests replacing cyclosporine as the systemic treatment over continued topical and systemic standard care. (L, C)
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Recommendation 22

In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the panel suggests against using methotrexate. (L, C)
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Recommendation 23

In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the panel suggests against using mycophenolate. (L, C)
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Recommendation 24

In patients with moderate-severe AD refractory, intolerant, or unable to use mid- to high-potency topical treatment and systemic treatment inclusive of a biologic recommended previously, the JTFPP panel suggests adding clinic-based narrow-band UV-B treatment. (L, C)
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Recommendation 25

In patients with atopic dermatitis, the JTF panel suggests against using systemic corticosteroids. (L, C)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Atopic Dermatitis (Eczema)

Authoring Organizations

American College of Allergy, Asthma, and Immunology

American Academy of Allergy, Asthma & Immunology

Publication Month/Year

December 17, 2023

Last Updated Month/Year

December 16, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of Atopic Dermatitis

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Treatment, Management

Diseases/Conditions (MeSH)

D003876 - Dermatitis, Atopic, D003872 - Dermatitis

Keywords

dermatitis, atopic dermatitis, exzema

Source Citation

AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel; Chu DK, Schneider L, Asiniwasis RN, Boguniewicz M, De Benedetto A, Ellison K, Frazier WT, Greenhawt M, Huynh J, Kim E, LeBovidge J, Lind ML, Lio P, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Wang J, Wheeler KE, Guyatt GH; Patient Groups, Global Parents for Eczema Research; Capozza K; National Eczema Association; Begolka WS; Evidence in Allergy Group; Chu AWL, Zhao IX, Chen L, Oykhman P, Bakaa L; AAAAI/ACAAI Joint Task Force on Practice Parameters; Golden D, Shaker M, Bernstein JA, Greenhawt M, Horner CC, Lieberman J, Stukus D, Rank MA, Wang J, Ellis A, Abrams E, Ledford D, Chu DK. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2023 Dec 15:S1081-1206(23)01455-2. doi: 10.1016/j.anai.2023.11.009. Epub ahead of print. PMID: 38108679.

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
298
Literature Search Start Date
June 1, 2022
Literature Search End Date
July 31, 2023