Am Fam Physician. 2024;110(4):437-439
Author disclosure: No relevant financial relationships.
KEY POINTS FOR PRACTICE
• Treatment of atopic dermatitis with a midpotency topical corticosteroid once daily or a topical calcineurin inhibitor two to three times per week is safer and more effective for maintenance of remission than episodic treatment of flare-ups.
• Dilute bleach baths are beneficial for moderate to severe cases of atopic dermatitis.
• Systemic corticosteroids, elimination diets, and topical antimicrobial agents should be avoided in patients with atopic dermatitis .
From the AFP Editors
The American Academy of Allergy, Asthma and Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters updated guidelines for managing atopic dermatitis (eczema). Table 1 summarizes recommendations relevant to family physicians.
| Treatment | Recommendation | Strength | Certainty |
|---|---|---|---|
| Topicals | Cases of any severity | ||
| Use over-the-counter moisturizers rather than prescription moisturizers | Conditional | Low | |
| Add a topical corticosteroid | Strong | High | |
| Add a topical calcineurin inhibitor | Strong | High | |
| If using mid- to high-potency topical treatment, apply once daily | Conditional | Moderate | |
| Use maintenance therapy with a low- to midpotency topical corticosteroid or topical calcineurin inhibitor | Strong | Moderate | |
| Avoid topical antimicrobials in patients with no clear signs of infection | Conditional | Very low | |
| Mild to moderate cases | |||
| Add crisaborole 2% ointment (available as brand Eucrisa) | Conditional | Moderate | |
| Dilute bleach baths | Moderate to severe cases | ||
| Use dilute bleach baths | Conditional | Low | |
| Mild cases | |||
| Avoid bleach baths | Conditional | Low | |
| Elimination diets | Cases of any severity | ||
| Avoid elimination diets | Conditional | Low |
EFFECTIVE THERAPIES
Recommended clinical practice includes ensuring the diagnosis is correct, discussing trigger avoidance, and supporting optimal medication and moisturizer use.
Moisturizers
Moisturizer therapy is critical for treatment of atopic dermatitis. Adherence is more important than the type of moisturizer used; therefore, the potential greater benefit of ointments compared with creams may be offset by patient intolerance. Systematic reviews have not shown a benefit of prescription moisturizers to justify the increased cost and inconvenience.
Topical Corticosteroids
Topical corticosteroids provide the largest improvements in patient-oriented outcomes and are strongly recommended when symptoms cannot be controlled with moisturizers alone. Randomized trials up to 6 weeks in duration show no significant increase in skin infections, atrophy, or other changes due to topical corticosteroids.
High-potency topical corticosteroids, such as clobetasol propionate 0.05% and fluocinonide 0.05%, should be applied for less than 4 continuous weeks at a time, with avoidance on sensitive areas, including the face, skin folds, and groin. Prolonged use of high-potency corticosteroids increases the rare risk of skin atrophy, telangiectasia, and striae, but these adverse effects can also occur with continuous use of lower-potency topical corticosteroids. Medication potency should be determined by the patient's previous treatment, site of application, cost, accessibility, and preferences.
Mid- or high-potency topical corticosteroids should be used only once daily. Twice-daily use offers minimal improvement.
Topical Calcineurin Inhibitors
Topical calcineurin inhibitors (tacrolimus 0.1% ointment or pimecrolimus cream) are effective as continued intermittent treatment and maintenance therapy for uncontrolled atopic dermatitis. Once-daily use is recommended to induce remission. Calcineurin inhibitors are a recommended option when atopic dermatitis cannot be optimally controlled with moisturizers alone. Combination treatment with topical corticosteroids and calcineurin inhibitors offers modest improvement, at best, compared with either agent by itself.
Local irritation and burning sensations are potential adverse effects of topical calcineurin inhibitors and are usually minor. These can be minimized by applying the medication after moisturizing, using topical corticosteroids for a few days before application, or cooling the tube of medication (i.e., refrigeration). Although the products are labeled with a warning about the risk of malignancy with long-term use, a systematic review found that regular use of these therapies among infants, children, and adults is not associated with an increase in cancer risk.
Topical Phosphodiesterase-4 Inhibitors
Crisaborole 2% ointment (available as brand Eucrisa) modestly improves atopic dermatitis severity, pruritus, and quality of life, similar to low-potency topical corticosteroids or pimecrolimus; however, crisaborole is expensive, and it increases local burning or stinging sensations. This topical agent is suggested for patients with mild atopic dermatitis refractory to moisturizer alone who strongly prefer to avoid topical coritcosteroids or calcineurin inhibitors.
Dilute Bleach Baths
In patients with moderate to severe disease, dilute bleach baths have a number needed to treat of 10 to improve symptoms, with few adverse effects, compared with regular baths. Symptoms may improve within 4 weeks. Dilute bleach baths provide little to no benefit in mild disease. Specific written instructions should be given to patients and caregivers to ensure the correct type and concentration of bleach is used. The National Eczema Association provides an appropriate bleach bath recipe.
LESS EFFECTIVE OR LESS SAFE THERAPIES
Topical Antimicrobials
Topical antimicrobial agents should be avoided because they provide little to no benefit when used alone or in combination with topical calcineurin inhibitors or topical corticosteroids.
Topical Janus Kinase Inhibitors
The guidelines recommend against using topical ruxolitinib 1.5% cream (available as brand Opzelura), a Janus kinase inhibitor, for treatment of mild to moderate atopic dermatitis refractory to moisturization. Although topical ruxolitinib improves atopic dermatitis severity, pruritus, sleep disturbance, and quality of life, the effects are modest, and the medication has a U.S. Food and Drug Administration boxed warning regarding increased risk of thrombosis, serious infections, malignancies, and mortality based on use of oral Janus kinase inhibitors. Patients using ruxolitinib should apply it to less than 20% of their body surface area and use it only intermittently. Topical corticosteroids and calcineurin inhibitors are safer and less expensive than topical Janus kinase inhibitors.
Elimination Diets
Elimination diets are minimally effective and can be harmful. Evidence suggests that tolerance to food allergens improves with frequent exposure in infants; therefore, elimination diets may also increase the risk of future food allergies. The guidelines recommend against elimination diets, with or without allergy testing, in all patients with atopic dermatitis. Elimination diets may also increase the risk of malnutrition.
Systemic Corticosteroids
Systemic corticosteroids should be avoided for treatment of atopic dermatitis. They may improve atopic dermatitis severity, but the effects are temporary and have little effect on quality of life, pruritus, or sleep disturbance. Discontinuation can cause worsening symptoms (rebound flare-ups). The potential adverse effects of corticosteroids (e.g., sepsis, venous thromboembolism, fracture) are significant with less than 30 days of use, and the repeated use of systemic corticosteroids increases the risk of fragility fractures, cardiac events, diabetes mellitus, and obesity.
MAINTENANCE THERAPY
After initial control of symptoms, continuous maintenance therapy reduces atopic dermatitis flare-ups by one-half compared with episodic therapy for recurrent symptoms. The guidelines strongly recommend maintenance therapy for patients with a relapsing course. Maintenance therapy entails once-daily use of a midpotency topical corticosteroid or use of a calcineurin inhibitor (tacrolimus or pimecrolimus) two to three times weekly.
REFERRAL
Patients with atopic dermatitis that remains poorly controlled despite optimal topical treatment should be referred to allergy-immunology or dermatology subspecialists. Allergy-immunology subspecialists can offer allergen immunotherapy; treatment with injectable biologics such as dupilumab (available as brand Dupixent) and tralokinumab (available as brand Adbry); and immunosuppressant therapy with oral Janus kinase inhibitors, cyclosporine, methotrexate, mycophenolate, and azathioprine. Dermatologists offer ultraviolet phototherapy in addition to biologics and immunosuppressant therapy.
| Score | Criteria |
|---|---|
| Yes | Focus on patient-oriented outcomes |
| Yes | Clear and actionable recommendations |
| Yes | Relevant patient populations and conditions |
| Yes | Based on systematic review |
| Yes | Evidence graded by quality |
| Yes | Separate evidence review or analyst in guideline team |
| No | Chair and majority free of conflicts of interest |
| Yes | Development group includes most relevant specialties, patients, and payers |
| Overall – useful |
Editor’s Note: Drs. Chu and Schneider were members of the development committee for this guideline.
This guideline provides a comprehensive summary for management of a condition that we often treat, and several of the practical recommendations are helpful, including use of dilute bleach baths for moderate and more severe cases and avoiding prescription moisturizers, topical antibiotics, and food elimination diets. Similar to many guidelines, numerous committee members have potential conflicts of interest. Dr. Schneider, who is both a guideline committee co-chair and one of the authors of this summary, reported industry-related research and writing on dupilumab (a biologic agent not extensively covered in this guideline), food allergy devices, and an atopic dermatitis handbook. On the guideline committee, Dr. Schneider recused herself from discussion of topics with a potential conflict. American Family Physician does not routinely accept authors with potential conflicts of interest, and these issues were not recognized until late in the editorial process. We believe this summary is an accurate reflection of the guideline and is not biased, yet we believe readers should be informed about this concern.
–Michael J. Arnold, MD, MHPE, Assistant Medical Editor
Guideline source: American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology
Published source: Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and ImmunologyJoint Task Force on Practice Parameters GRADE- and Instititute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274–312.
