Management Of Atopic Dermatitis: Management And Treatment Of Atopic Dermatitis With Topical Therapies
Publication Date: July 1, 2014
Last Updated: March 14, 2022
Recommendations
NONPHARMACOLOGIC INTERVENTIONS
The application of moisturizers should be an integral part of the treatment of patients with AD as there is strong evidence that their use can reduce disease severity and the need for pharmacologic intervention. (A)
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Bathing is suggested for patients with AD as part of treatment and maintenance; however, there is no standard for the frequency or duration of bathing appropriate for those with AD. (C)
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Moisturizers should be applied soon after bathing to improve skin hydration in patients with AD. (B)
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Limited use of nonsoap cleansers (that are neutral to low pH, hypoallergenic, and fragrance free) is recommended. (C)
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For the treatment of patients with AD, the addition of oils, emollients, and most other additives to bath water and the use of acidic spring water cannot be recommended at this time, because of insufficient evidence. (C)
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Use of wet-wrap therapy with or without a topical corticosteroid can be recommended for patients with moderate to severe AD to decrease disease severity and water loss during flares. (B)
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TOPICAL CORTICOSTEROIDS
Topical corticosteroids are recommended for AD-affected individuals who have failed to respond to good skin care and regular use of emollients alone. (A)
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A variety of factors should be considered when choosing a particular topical corticosteroid for the treatment of AD, including patient age, areas of the body to which the medication will be applied, and other patient factors such as degree of xerosis, patient preference, and cost of medication. (C)
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Twice-daily application of corticosteroids is generally recommended for the treatment of AD; however, evidence suggests that once-daily application of some corticosteroids may be sufficient. (B)
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Proactive, intermittent use of topical corticosteroids as maintenance therapy (1-2 times/wk) on areas that commonly flare is recommended to help prevent relapses and is more effective than use of emollients alone. (A)
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The potential for both topical and systemic side effects, including possible hypothalamic-pituitary-adrenal axis suppression, should be considered, particularly in children with AD in whom corticosteroids are used. (B)
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Monitoring by physical examination for cutaneous side effects during long-term, potent steroid use is recommended. ()
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No specific monitoring for systemic side effects is routinely recommended for patients with AD. ()
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Patient fears of side effects associated with the use of topical corticosteroids for AD should be recognized and addressed to improve adherence and avoid undertreatment. ()
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TOPICAL CALCINEURIN INHIBITORS
TCI are recommended and effective for acute and chronic treatment, along with maintenance, in both adults and children with AD, and are particularly useful in selected clinical situations. (A)
Clinical situations in which topical calcineurin inhibitors may be preferable to topical steroids:
- Recalcitrance to steroids
- Sensitive areas (eg, face, anogenital, skin folds)
- Steroid-induced atrophy
- Long-term uninterrupted topical steroid use
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TCI are recommended for use on actively affected areas as a steroid-sparing agent for the treatment of AD. (A)
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For patients with AD ≤2 years of age with mild to severe disease, off-label use of 0.03% tacrolimus or 1% pimecrolimus ointment can be recommended. (A)
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Pimecrolimus cream and tacrolimus ointment may cause skin burning and pruritus, especially when applied to acutely inflamed skin. Initial treatment of patients with AD using topical corticosteroids should be considered to minimize TCI application site reactions. Patients with AD should be counseled about the possibility of these reactions. (B)
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Proactive, intermittent use of TCI as maintenance therapy (2-3 times per week) on areas that commonly flare is recommended to help prevent relapses while reducing the need for topical corticosteroids, and is more effective than the use of emollients alone. (A)
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The concomitant use of a topical corticosteroid with a TCI may be recommended for the treatment of AD. (B)
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No consistent increases in the prevalence of cutaneous viral infections have been seen with continuous or intermittent use of TCI for up to 5 years; however, physicians should inform their patients of these theoretical cutaneous risks, given the lack of safety data for longer periods of time. (C)
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Clinicians should be aware of the black-box warning on the use of TCI for patients with AD and discuss as warranted. (C)
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Routine blood monitoring of tacrolimus and pimecrolimus levels in patients with AD who are applying these agents is not recommended at this time. (A)
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TOPICAL ANTIMICROBIALS AND ANTISEPTICS
Except for bleach baths with intranasal mupirocin, no topical antistaphylococcal treatment has been shown to be clinically helpful in patients with AD, and is not routinely recommended. (A)
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In patients with moderate to severe AD and clinical signs of secondary bacterial infection, bleach baths and intranasal mupirocin may be recommended to reduce disease severity. (B)
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The use of topical antihistamines for the treatment of patients with atopic dermatitis is not recommended because of the risk of absorption and of contact dermatitis. (B)
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Recommendation Grading
Overview
Title
Management Of Atopic Dermatitis: Management And Treatment Of Atopic Dermatitis With Topical Therapies
Authoring Organization
American Academy of Dermatology
Publication Month/Year
July 1, 2014
Last Updated Month/Year
June 27, 2023
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Document Objectives
This guideline addresses the management of pediatric and adult atopic dermatitis (AD; atopic eczema) of all severities
Target Patient Population
Pediatric and adult atopic dermatitis patients
Target Provider Population
Dermatologists and other providers who treat atopic dermatitis patients
Inclusion Criteria
Female, Male, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management, Treatment
Diseases/Conditions (MeSH)
D003876 - Dermatitis, Atopic
Keywords
atopic dermatitis, exzema
Methodology
Number of Source Documents
130
Literature Search Start Date
November 1, 2003
Literature Search End Date
November 1, 2012