Treatment and Guidelines

Effective AD management requires a strategic, multimodal approach. This page is designed to guide you through:

• Therapeutic overview for a classification of available treatments with specific clinical examples.
• Clinical Guidelines on current gold-standard recommendations for evidence-based care in active disease and maintenance. 

Preventative

The best preventive care for AD is moisturization, as it enhances the skin barrier to protect from allergens, pathogens and injury while also reducing water loss, which can predispose skin damage. The recommendation is to apply fragrant-free, thick texture with low water content moisturizer daily, especially after bath, shower or hand washing. 

Avoiding triggers such as low humidity, and skin irritants like harsh soaps, detergents, and contact allergens should be recommended to patients with eczema. In addition, daily short baths with lukewarm water and gentle cleaners, with an emphasis on moisturizer immediately after, is the most common pediatric dermatologist recommendation for patients with eczema (2).

Before initiating any new therapy (2):

1. Ensure correct diagnosis and identify complicating diagnoses
2. Provide education
   • Information guide of disease
   • Action plan
3. Address trigger avoidance
4. Ensure proper medication use/adherence
5. Encourage application of a fragrance-free, dye-free, and additive-free moisturizer as needed for symptomatic benefit

Treatment

Topical Options

Moisturizers

• Bland and could be oat-based, ceramide-based, glycerol-based, urea-based, etc.
• Best choice should be based on what will be regularly used and factor in:
  • Form (lotion, cream, gel, or ointment) based on benefits and shared decision-making
  • Cost, acceptability, and accessibility

Prescription Moisturizers

Atopiclair, Eletone, Epiceram, MimyX, Neosalus, Zenieva, and PruMyx

Corticosteroids

High, medium, and low potency

Calcineurin Inhibitors

Pimecrolimus, Tacrolimus 0.1% (high-dose), Tacrolimus 0.03% (low-dose)

Phosphodiesterase 4 inhibitors

Crisaborole, Difamilast, Lotamilast, Roflumilast

Janus kinase inhibitors

Delgocitinib, Delgocitinib ointment, Ruxolitinib 

Antimicrobials

Guidelines

Active AD disease

Use a standard, bland OTC moisturizer over a prescription moisturizer medical device with the following considerations (1):

1. Odor and texture/consistency of moisturizers
2. Insurance plans that cover cost of prescription moisturizer or easily absorb direct cost and place a higher value on prescriptive benefits over costs, burdens, and lower accessibility
3. Patients who have not improved sufficiently with routine use of standard OTC moisturizer may prefer trial of prescription moisturizer before adding topical anti-inflammatory medications

For a patient with uncontrolled AD refractory to moisturization alone, the addition of a topical corticosteroid (TCS) is strongly recommended (1).

• The introduction of TCS is not governed by a fixed timeline, but rather indicated upon the failure of optimized emollient therapy 
• There are high (group 1 and 2), medium (group 3 and 4), and low (grade 5 and 6/7) potency
• Exactly which TCS to use depends on previous treatment history, site of applications, cost, accessibility, values, and preferences
• Avoid high-potency for prolonged periods (>4 weeks) and limit its use on sensitive areas like face, folds, or groin
• Action plans could help if required to have different potency for different sites of the body, depending on severity of AD activity

In patients 2 years or older with uncontrolled AD to moisturization alone, the addition of topical calcineurin inhibitor (TCI) is strongly recommended (1)

• Pimecrolimus and Tacrolimus 0.03% approved for 2 years and older
• Tacrolimus 0.1% approved for 16 years and older
• Can be utilized for more sensitive areas like face and folds
• Great option for AD flares
• However, there is low evidence that the combination of TCS and TCI have added benefits compared to using either agent alone

When to apply TCS or TCI (1):

• Suggests applying once per day to twice per day with consideration of conditions
  • Patients that value simpler treatment routine and use less overall medication (1)
  • Patients with severe flare or value resolving it more quickly may prefer twice per day
  • Patients who value twice per day skin routine or who respond better to twice per day use
  • Tailor frequency to patient values of therapy as needed to help promote self-efficacy

Under Occlusion/Wet wraps vs Standard Nonocclusive Application (1)

• For patients with localized uncontrolled AD refractory to class 2-5 TCS or tacrolimus, there is conditional suggestion for addition of class 3-7 TCS occlusive therapy over continued standard topical therapy alone (1).
  • Apply for 4-7 days for minimum of 1 hour to maximum overnight once per day
• Consider
  • Resources and time to educate
  • Location of AD lesions
  • Feasibility of incorporating into schedule and daily routines
  • Patients with more extensive disease or relapsing lesions may prefer systemic therapy
• Best utilized for specific local treatment of lesions/flares
• Wraps could be pajamas, clothes, socks for hands, but ensure not constrictive
• Be careful of potential harms: local irritation (maceration or folliculitis)
• NO evidence for TCI treatment under occlusion

PDE4 inhibitor (crisaborole 2% ointment (Eucrisa) and Roflumilast cream (Zoryve)) addition is conditionally recommended for mild-moderate AD refractory to moisturization alone (1).

• Consider
  • Age
    • Crisaborole >3 months of age
    • Roflumilast
      • 0.15% cream: ≥6 years of age once daily
      • 0.05% cream: 2 to 5 years of age once daily
  • Adverse effects more prominent to sensitive areas
    • Local irritation with stinging and burning
  • Severity: Treats mild AD flares and smaller benefits in severe cases
  • Patients that highly value noncorticosteroid treatments 
• Small improvements in achieving AD remission, itch, quality of life, and reducing chance of flare

JAK inhibitor (Ruxolitinib) addition is conditionally recommended for adolescents and adult patients with mild-mod AD refractory moisturization alone (1).

• Consider
  • Patients placing higher value on larger benefits and safety of other topical treatments and certain systemic therapies
  • Immunocompromised/suppressed, serious infection, cancer, thrombosis, or CV events prefer other treatments
  • Favorable for patients who have not responded to other topical therapies, value the modest benefits, and not worried about associated potential risks
• Improvement in AD severity, itch, sleep disturbance, and quality of life but uncertain about reduction of flares
• Concern with systemic absorption sufficient enough to limit application to less than 20% BSA and use in a discontinuous manner
• Most patients avoid due to uncertain increase in death, cancer, thrombosis, and serious infections, particularly with safer treatment options

Antimicrobial addition to standard topical treatments is conditionally NOT recommended in patients with uncontrolled AD with no serious bacterial skin infection (1).

• Consider
  • Patients who place a high value on polypharmacy and antimicrobial resistance prefer avoiding adding to standard care. For severe skin infections, guidance from the Infectious Disease Society of America addresses when to use systemic or topical antimicrobials.
  • Preferred addition for those who are immunocompromised or suppressed, severe infection or history of severe infections, severe AD, or who place high value on avoiding complications of bacterial skin infections 
• Education of inflammatory nature of AD impairing natural antimicrobial defense and framing importance of anti-inflammatory to control AD is critical to address and prevent future ones

Maintenance of Remission: Important to prevent flares, escalation of therapy, associated complications of AD, and medication adverse effects (1).

Class 3-5 TCS or TCI are strongly recommended for use of proactive therapy to areas that frequently flare (1).

• Application once per day on 2 consecutive days per week for several months to maintain AD control
• Weekends would potentially be the best time but recommend days that make the most sense for family and patient 

Dilute Bleach Baths are conditionally recommended for patients with moderate-to-severe AD in addition to topical therapy (1).

• Consider
  • How these baths will fit into routine
  • Used as an adjunct to otherwise good skin care
  • Provisions are clear and written instructions are provided
  • Extent of open skin (cracks, fissures, excoriations) may make the bath less tolerable to some patients 
• Likely to see effects in AD severity within 4 weeks
• Conditional due to low certainty of benefits and potential harms with open skin

In patients with mild atopic dermatitis, dilute bleach baths are conditionally NOT recommended to add to topical therapy (1):

• Consider
  • Magnitude of benefit in AD severity is smaller in those with less severe disease; however, some may opt in for adjunctive therapy even with mild activity

Elimination Diets with or without skin testing is conditionally NOT recommended with AD compared with an unrestricted diet (1).

• Consider
  • Young age of patient and risk factors for developing IgE-mediated food allergy favor against pursuing elimination diet
  • Risk for malnutrition
• This carries a high risk of false-positive results, which may lead to unnecessary dietary restriction in sensitized but asymptomatic infants, subsequently increasing the risk of developing a true IgE-mediated food allergy.
• Those who pursue this provide strategies to mitigate harm; what managing a food allergy entails and scheduling close follow-up (w/i 4 weeks)

Referral would be required for these treatment options (1):

• Allergen Immunotherapy
• Systemic treatments
• Narrow-band UV-B light

Links to Helpful Guidelines

Atopic dermatisis guideline 2023 (side 1)

Atopic dermatisis guidelines 2023 (side 2)

References

1. Chu, D. K., Schneider, L., Asiniwasis, R. N., Boguniewicz, M., Casale, T. B., Chu, A. W. L., Eigenmann, P. A., Fleischer, D. M., Greenhawt, M., Horner, C. C., Mack, D. P., Milner, J. D., Oppenheimer, J., Schneider, A. T., Searing, D. A., Spergel, J. M., Stukus, D. R., Venter, C., Wang, J., … Golden, D. B. K. (2024). Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Annals of Allergy, Asthma & Immunology, 132 (3), 274–312.

2. Schoch, J. J., Anderson, R. K., Jones, A. E., Tollefson, M. M., & Section on Dermatology. (2025). Atopic dermatitis: Update on skin-directed management: Clinical report. Pediatrics, 155(6), Article e2025071812.