Treatment of atopic dermatitis (eczema)

Adult chronic atopic dermatitis - Lichenified, hyperpigmented plaque in the elbow flexure of a 35-year-old woman with atopic dermatitis.
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SUMMARY AND RECOMMENDATIONS

● The goals of treatment for atopic dermatitis are to reduce symptoms (pruritus and dermatitis), prevent exacerbations, and minimize therapeutic risks.

● The optimal management requires a multipronged approach that involves the elimination of exacerbating factors, restoration of the skin barrier function and hydration of the skin, patient education, and pharmacologic treatment of skin inflammation.

● We suggest that patients with mild to moderate atopic dermatitis be initially treated with topical corticosteroids and emollients (Grade 2B). The choice of the corticosteroid potency should be based upon the patient’s age, body area involved, and degree of skin inflammation.
• For patients with mild atopic dermatitis, we suggest a low potency (groups five and six (table 1)) corticosteroid cream or ointment (eg, desonide 0.05%, hydrocortisone 2.5%). Topical corticosteroids can be applied once or twice daily for two to four weeks.
• For patients with moderate disease, we suggest medium to high potency (groups three and four (table 1)) corticosteroids (eg, fluocinolone 0.025%, triamcinolone 0.1%, betamethasone dipropionate 0.05%).
• The face and skin folds are areas that are at high risk for atrophy with corticosteroids. Initial therapy in these areas should start with a low potency corticosteroid (group VI (table 1)), such as desonide 0.05% ointment for up to three weeks.

● We suggest that patients with atopic dermatitis involving the face or skin folds that is not controlled with topical corticosteroids, be treated with a topical calcineurin inhibitor (ie, tacrolimus or pimecrolimus) (Grade 2B).

● We suggest proactive therapy to prevent relapse in adolescents and adults with moderate to severe (picture 1A-B) atopic dermatitis that responds to continuous therapy with topical corticosteroids or calcineurin inhibitors (Grade 2A). We suggest medium to high potency topical corticosteroids (groups three to five) (table 1) rather than topical calcineurin inhibitors for proactive intermittent therapy (Grade 2B). Topical corticosteroids are applied once daily for two consecutive days per week for up to 16 weeks.

● Patients with moderate to severe atopic dermatitis that is not controlled with optimal topical therapy may require phototherapy or systemic immunosuppressant treatment to achieve adequate disease control. These treatments are not suitable for infants and young children. In older children and adolescents, they should be used when other management options have failed and the disease has a significant impact on the quality of life.

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