Patient and caregiver education are important factors for successful management of AD. Chronic scratching or rubbing should be strongly discouraged. Written information and instructions should be given to reinforce the treatment plan, skin care practices, appropriate medication use, and flare management.
Addressing appropriate daily skin care practices is a key feature of AD management. The frequency of bathing is controversial. Cleansing once per day or once every other day, as well as keeping baths or showers under 10 minutes so as not to worsen xerosis, is often recommended. Cleansing the skin allows for superficial debridement and improved penetration of topical therapies. Immediately after leaving the bath or shower, the skin should be patted dry with a towel, keeping the skin slightly wet and followed by liberal application of moisturizers or emollients. This technique helps prevent excessive drying of the skin and moisture loss. Ointments, although greasy, are generally more effective moisturizers than creams or lotions. A multitude of over-the-counter moisturizers are available both in stores and online, and greater expense may not portend greater efficacy. Moisturizers rich in ceramides are a good option. Patients should be advised to observe for signs of complications such as impetigo and herpes.
Credible educational resources are available for patients and care givers. Clinicians can direct patients to the American Academy of Dermatology (AAD), the National Eczema Association, the Eczema Society of Canada, and the Canadian Skin Alliance) for further information.
For younger patients with AD, a book titled Under My Skin by Karen Crowe is a helpful resource. This “kid’s guide to atopic dermatitis” helps children to better comprehend their disease.
Management of AD is best accomplished by repairing the damaged skin barrier and minimizing inflammation. Patient education should stress the need for moisturization, avoidance of excessive scratching and rubbing, and elimination of known exacerbating factors such as wearing wool clothing and excessive bathing or hand washing. If flares are associated with emotional stress, stress reduction strategies and psychiatry referral may be indicated.
First-line pharmacologic treatment for AD is topical corticosteroids, which improve AD through immunosuppressive, anti-inflammatory, and antiproliferative actions. Potency of topical steroids ranges from low to high, with the latter usually reserved for acute flares. Topical corticosteroids should be applied directly to itchy, red, or inflamed areas prior to the application of emollients or other moisturizers so as to not decrease the efficacy of the steroid.11
Choice of topical corticosteroid is often based on familiarity and patient access (ie, out-of-pocket cost). In sensitive areas where skin is the thinnest — such as the face, neck, groin, and underarms — use of a low-potency topical corticosteroid such as hydrocortisone acetate is recommended. For xerotic skin, ointment preparations are preferred over creams or lotions as they provide higher degrees of penetration and more uniform coverage. With prolonged use, topical corticosteroids may cause skin depigmentation, striae, and atrophy. Suppression of the pituitary-adrenal axis may also occur.11
Topical calcineurin inhibitors (TCIs) are safe and effective for the treatment of AD and may prevent AD flares.12 These agents are commonly used as second-line intermittent therapy; both pimecrolimus and tacrolimus are approved by the US Food and Drug Administration (FDA) to treat AD in immunocompetent patients aged ≥2 years. In one study, tacrolimus 0.1% was as effective as potent topical corticosteroids such as betamethasone.13 On direct comparison of tacrolimus 0.03% against pimecrolimus 1% in children with moderate AD, no significant difference was seen.14 Due to the high cost of TCIs, these agents are typically reserved for patients with persistent disease, patients requiring frequent or continuous topical corticosteroids, or patients in whom AD affects sensitive areas of skin such as the face or neck where risk of skin atrophy from topical corticosteroid use is increased. Skin burning and irritation are the most common adverse effects seen with TCIs. Due to the theoretical risk of skin malignancy and lymphoma in patients using these agents, the FDA recommends caution when prescribing TCIs.12
A new novel topical anti-inflammatory, crisaborole 2% ointment, has been approved by the FDA to treat mild to moderate AD in patients aged ≥2 years. Crisaborole 2% ointment is a phosphodiesterase 4 (PDE4) inhibitor. In clinical studies, crisaborole ointment 2% has been shown to be well tolerated with a favorable safety profile.15 Crisaborole may provide effective long-term treatment of AD without the safety concerns associated with topical corticosteroids.15
Patients with AD may be heavily colonized with S aureus both in involved and uninvolved sites. Due to barrier impairment, patients with AD are at increased risk for secondary infection. Topical or oral antibiotic therapy is recommended when a bacterial infection is present.
Patients with atopy are prone to recurrent viral infections such as eczema herpeticum (also known as Kaposi varicelliform eruption), which is a widespread herpes infection that occurs at sites of skin damage. Eczema herpeticum is most common in severe AD and may be misdiagnosed as a bacterial infection. Treatment includes systemic antiviral agents such as acyclovir or valacyclovir. Children with AD are also more prone to infection with molluscum contagiosum. This condition is often asymptomatic and self-limiting. Lesions tend to resolve slowly but may spread to other sites.