Atopic dermatitis (AD) is a chronic, relapsing inflammatory skin disease. Management follows a stepped, multifaceted approach.
1. Prescription Therapies (Stepwise)
- Topical corticosteroids (TCS): First‑line for flares. Potency matched to site/severity (face/folds: low; body: mid‑high). Proactive intermittent use (weekend therapy) prevents relapse.
- Topical calcineurin inhibitors (TCI): Tacrolimus, pimecrolimus — steroid‑sparing for face/folds/maintenance.
- Crisaborole (PDE4 inhibitor): Non‑steroidal, mild‑mod AD.
- Biologics (dupilumab, tralokinumab): Mod‑severe refractory AD; target IL‑4/13.
- JAK inhibitors (upadacitinib, abrocitinib): Oral, mod‑severe; monitor labs.
- Phototherapy (NB‑UVB): Widespread disease unresponsive to topicals.
2. Daily Skin Barrier Repair
- Cleanser: Non‑soap, pH‑balanced, fragrance‑free (syndet).
- Moisturize 2–3×/day: Ointment > cream > lotion. Ceramides, glycerin, petrolatum. Apply within 3 min of bathing ("soak and seal").
- Bathing: Lukewarm, 5–10 min; bleach baths (½ cup/40 gal) 2×/wk if colonized.
3. Trigger Avoidance
- Identify via diary: fragrances, wool, heat/sweat, allergens (dust mite, pet), foods (if proven).
- Laundry: fragrance‑free detergent, double rinse, no fabric softener.
4. Itch Management
- Cool compresses, wet wraps (for severe flares).
- Antihistamines: sedating (night) for sleep; non‑sedating less effective for AD itch.
5. Psychosocial Support
- Stress → flare cycle: CBT, mindfulness, habit reversal.
- Sleep hygiene — critical for immune regulation.
6. When to Escalate
- Infection signs (honey crust, pustules, fever) → antibiotics.
- Erythroderma, eczema herpeticum → emergency.
- Quality of life severely impacted → specialist referral.
Consistency with barrier care is the foundation; medications control inflammation. Partnership with a dermatologist optimizes long‑term control.
