Atopic dermatitis is a chronic inflammatory skin disease most commonly occurring in children with a variable course, but can also first appear in adulthood. Therapy should be approached on the basis of disease severity, which includes the intensity of skin lesions, the extent of body surface involvement, symptom burden, and the rapidity of recurrent disease after clearance. Mild disease usually responds to intermittent low-potency topical corticosteroids (TCS), with bland emollients effective for prevention of flares. Moderate-to-severe disease usually requires a combination approach of TCS for clearance and the use of nonsteroidal topical therapies to safely maintain control in a reactive or proactive fashion. Patients with moderate-to-severe disease not controlled with topical therapies should be considered for phototherapy or systemic therapy.1 See Table 1-1.
Table Graphic Jump Location Table 1-1Atopic Dermatitis Treatment Table ||Download (.pdf) Table 1-1 Atopic Dermatitis Treatment Table
|MEDICATION NAME ||INDICATION ||MECHANISM OF ACTION ||DOSING ||ADVERSE EFFECTS (SELECTED AEs OF INTEREST) ||SUGGESTED MONITORING ||LEVEL OF EVIDENCE (REFERENCE) |
|Topical Therapy |
|Corticosteroidsa ||Any severity. 7 classes of potency. Choice of medication reflects disease severity, location, and patient age ||Anti-inflammatory ||Lowest potency (face/anogenital area): hydrocortisone 1% ointment BID; highest potency (palms/soles): clobetasol propionate 0.05% ointment BID ||Skin irritation, skin atrophy, purpura, telangiectasia, striae, focal withdrawal syndrome, and acneiform or rosacea-like eruption ||Periodic monitoring for cutaneous changes by physical examinationb ||IA2 |
|Calcineurin inhibitorsf || |
Mild-to-moderate disease: pimecrolimus
Moderate-to-severe disease: tacrolimus
|Anti-inflammatory || |
Pimecrolimus 1% cream BID; tacrolimus 0.03%, 0.1% ointment BID
Pediatric > 2 y/o: pimecrolimus 1% cream BID; tacrolimus 0.03% ointment BID until age 15c
|Skin irritation (burning sensation, stinging pruritus, erythema) ||None ||IA3 |
|Crisaborolea ||Mild-to-moderate disease ||Phosphodiesterase 4 (PDE-4) inhibitor ||Adults and pediatric patients ages 3 months and up: 2% ointment BID ||Application site pain ||None ||IA4 |
|Ruxolitinibf ||Mild-to-moderate disease ||Janus kinase 1 and 2 inhibitors; immunomodulators ||Adults and pediatric patients ages 12 and up: 1.5% cream BID, limited to 20% BSA ||Nasopharyngitis ||None ||1B5 |
|Emollients ||Mild-to-severe disease ||Occlusive and humectant agent || |
Apply BID-TID up to 500 g weekly
Pediatric: apply BID-TID, up to 150-200 g weekly
|Folliculitis, contact dermatitis ||None ||IA6 |
|Systemic Therapy |
|Azathioprinef ||Moderate-to-severe disease ||Immunosuppressive || |
1-3 mg/kg QD
Pediatric: 1-4 mg/kg QD
|Pregnancy category D, bone marrow suppression, increased risk of infections and malignancies, GI symptoms, hypersensitivity syndrome, pancreatitis, hepatitis || |
Baseline: TPMT. Twice/monthly × 2 mo, monthly × 4 mo, then every other month with dose increase: CBC/differential/platelets, renal function, LFTs.
Annually: hepatitis B and C, TB, HIV, and HCG if indicated
|Cyclosporinef ||Moderate-to-severe disease (Maximum 1 y of treatment recommended) ||Immunosuppressive || |
Adult: 2.5-5 mg/kg divided BID
Pediatric: 3-6 mg/kg divided BID
|Pregnancy category C, headache, renal impairment, electrolyte disorders, HTN, tremors, paresthesia, hypertrichosis, gingival hyperplasia, GI symptoms, increased risk of infection and malignancies |
Every visit: blood pressure.
Every 2 wk for 2-3 mo, then monthly: renal function, LFTs, ...