Use of dilute bleach baths to prevent secondary infections is controversial. Dilute bleach baths can reduce S aureus colonization and, in some cases, avoid the need for systemic antibiotics. Dilute bleach baths involve adding one-quarter to one-half cup of chlorine bleach to a full bath, and patients are instructed to soak for approximately 10 minutes. After soaking, patients should rinse immediately with fresh water, pat the skin dry, and apply emollient or moisturizer to avoid drying or dehydrating the skin.1 Some studies report that twice-weekly bleach baths for 3 months are effective in AD management.16 However, a more recent analysis found them to be no more effective than water baths alone.17
Cyclosporine, methotrexate, and azathioprine are systemic immunosuppressive agents that are used to manage patients with severe AD refractory to topical therapies.18 Due to potential adverse effects associated with these agents, all patients should be monitored frequently. Kidney impairment may be seen with cyclosporine; therefore, creatinine and blood pressure should be monitored. Myelosuppression can occur in patients treated with azathioprine, and blood counts should be closely followed, especially at the onset of therapy.19 Methotrexate can induce liver fibrosis, and obese individuals and those with alcohol dependency are at greatest risk.18
Prolonged use of oral steroids should be avoided due to the potential for osteonecrosis and bone fracture. Short-term use can raise blood sugar and blood pressure.20 Intramuscular triamcinolone administered at 3-month intervals can be effective in managing flares and maintaining low disease activity, decreasing both inflammation and pruritus.21
First-generation antihistamines such as hydroxyzine and diphenhydramine have minimal effect on the pruritus accompanying AD, but their sedative effect may improve overall quality of life for those experiencing sleep disturbance.22 Second-generation antihistamines may be recommended for AD patients with allergy-associated triggers. In patients with AD and concomitant aeroallergen sensitization, allergen-specific immunotherapy may be beneficial.23
Ultraviolet (UV) light phototherapy administered for up to 8 weeks may prove of value for those patients for whom topical therapies are ineffective.24 UVB is a carcinogen and should be used cautiously in patients with fair skin and/or a personal or family history of skin cancer.
Wet-wrap therapy, which includes the application of wet bandages or dressings over AD-associated lesions after the application of emollients and/or topical corticosteroids, may be an effective therapy for AD flares. Similarly, the use of plastic wraps over the application of topical corticosteroids or emollients may be beneficial in aiding penetration of applied topical agents when treating AD flares. Although wet wraps are not superior to conventional topical therapies, they have shown value when used in conjunction with topical agents such as corticosteroids and emollients.25
Dupilumab, an interleukin 4 (IL-4) receptor α-antagonist, has been approved both in the United States and Europe for the treatment of AD and has revolutionized management of severe disease. Dupilumab blocks the shared IL-4α subunit from signaling IL-4 and IL-13, thereby reducing the TH2 inflammatory response.26 Clinical trials demonstrate marked superiority to placebo, especially when used in conjunction with topical steroids.27,28 The most common adverse events reported are conjunctivitis, nasopharyngitis, upper respiratory tract infection, injection site reaction, and skin infections.26
Additional topical and systemic therapies, including the oral Janus kinase inhibitor tofacitinib citrate, have shown promise in phase 3 clinical trials29 and will further enhance our ability to manage AD.
It is important to carefully monitor patients with AD and assess progress and/or exacerbations on a regular basis. These visits will allow for evaluation of the efficacy of current therapy, patient tolerability, medication risks, and patient adherence to the treatment plan.
Lauren Ax, MSPAS, PA-C is a nationally certified dermatology physician assistant licensed in Pennsylvania. She received her Masters of Science in Physician Assistant Studies at King’s College, where she graduated with honors. Lauren specializes in medical and cosmetic dermatology, treating both children and adults. She is passionate about providing dermatologic and medical care to underdeveloped areas around the world. She served on a medical mission trip to Port-au-Prince, Haiti, in May 2018, during which time she volunteered in a local clinic and orphanage treating skin and medical disorders to those with no access to medical care. Lauren is currently working in Hazelton, Pennsylvania, as a dermatology physician assistant at DermDOX Dermatology Centers.
- Krakowski AC, Eichenfield LF, Dohil MA. Management of atopic dermatitis in the pediatric population. Pediatrics. 2008;122(4):812-824.
- Kapur S, Watson W, Carr S. Atopic dermatitis. Allergy Asthma Clin Immunol. 2018;14(Suppl3):52.
- Larsen FS, Hanifin JM. Epidemiology of atopic dermatitis. Immunol Allergy Clin North Am. 2002;22(1):1-24.
- Kelleher M, Dunn-Galvin A, Hourihane JO, et al. Skin barrier dysfunction measured by transepidermal water loss at 2 days and 2 months predates and predicts atopic dermatitis at 1 year. J Allergy Clin Immunol. 2015;135(4):930-935.
- Pyun BY. Natural history and risk factors of atopic dermatitis in children. Allergy Asthma Immunol Res. 2015;7(2):101–105.
- Bieber T. Atopic dermatitis. N Engl J Med. 2008;358:1483-1494.
- Akdis CA, Akdis M, Bieber T, et al; for the European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology et al. Diagnosis and treatment of atopic dermatitis in children and adults: European Academy of Allergology and Clinical Immunology/American Academy of Allergy, Asthma and Immunology/PRACTALL Consensus Report. J Allergy Clin Immunol. 2006;118(1):152-169.
- Brown SJ, McLean WH. One remarkable molecule: filaggrin. J Invest Dermatol. 2012;132(3 Pt 2):751-762.
- Maliyar K, Sibbald C, Pope E, Sibbald GR. Diagnosis and management of atopic dermatitis: a review. Adv Skin Wound Care. 2018;31(12):538-550
- Williams HC, Burney PG, Hay RJ, et al. The U.K. Working Party’s diagnostic criteria for atopic dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis. Br J Dermatol. 1994;131(3):383-396.
- Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical therapies. J Am Acad Dermatol. 2014;71 (1):116-132.
- Ashcroft DM, Dimmock P, Garside R, Stein K, Williams HC. Efficacy and tolerability of topical pimecrolimus and tacrolimus in the treatment of atopic dermatitis: meta-analysis of randomized controlled trials. BMJ. 2005;330(7490):516.
- Reitamo S, Rustin M, Ruzicka T, et al; European Tacrolimus Ointment Study Group. Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone butyrate ointment in adult patients with atopic dermatitis. J Allergy Clin Immunol. 2002;109(3):547-555.
- Kempers S, Boguniewicz M, Carter E, et al. A randomized investigator-blinded study comparing pimecrolimus cream 1% with tacrolimus ointment 0.03% in the treatment of pediatric patients with moderate atopic dermatitis. J Am Acad Dermatol. 2004;51(4):515-525.
- Hoy SM. Crisaborole 2% ointment: a review in mild to moderate atopic dermatitis. Am J Clin Dermatol. 2017;18(6):837-843.
- Huang JT, Abrams M, Tlougan B, Rademaker A, Paller AS. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009;123(3):e808-e814.
- Chopra R, Vakharia PP, Sacotte R, Silverberg JI. Efficacy of bleach baths in reducing severity of atopic dermatitis: a systematic review and meta-analysis. Ann Allergy Asthma Immunol. 2017;119(5):435-440.
- Simon D, Bieber T. Systemic therapy for atopic dermatitis. Allergy. 2013;69(1):46-55.
- Anstey AV, Wakelin S, Reynolds, NJ. Azathioprine: guidelines for prescribing azathioprine in dermatology. Br J Dermatol. 2004;151(6):1123-1132.
- Yu SH, Drucker AM, Lebwohl M, Silverberg JI. A systematic review of the safety and efficacy of systemic corticosteroids in atopic dermatitis. J Am Acad Dermatol. 2018;78(4):733-740.
- Buys LM. Treatment options for atopic dermatitis. Am Fam Physician. 2007;15;75(4):523-528.
- Matterne U, Böhmer MM, Weisshaar E, Jupiter A, Carter B, Apfelbacher CJ. Oral H1 antihistamines as ‘add-on’ therapy to topical treatment for eczema. Cochrane Database Syst Rev. 2019 Jan 22;1:CD012167.
- Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol. 2011;127(1 Suppl):S1-S55.
- Patrizi A, Raone B, Ravaioli GM. Safety and efficacy of phototherapy in the management of eczema. Adv Exp Med Biol. 2017;996:319-331.
- González-López G, Ceballos-Rodríguez RM, González-López JJ, Feito Rodríguez M, Herranz-Pinto P. Efficacy and safety of wet wrap therapy for patients with atopic dermatitis: a systematic review and meta-analysis. Br J Dermatol. 2017;177(3):688-695.
- Gooderham MJ, Hong HC, Eshtiaghi P, Papp KA. Dupilumab: a review of its use in the treatment of atopic dermatitis. J Am Acad Dermatol. 2018;78(3 Suppl 1):28-36.
- Blauvelt A, de Bruin-Weller M, Gooderham M, et al. Long-term management of moderate-to-severe atopic dermatitis with dupilumab and concomitant topical corticosteroids (LIBERTY AD CHRONOS): a 1-year, randomized, double-blinded, placebo-controlled, phase 3 trial. Lancet. 2017;389(10086):2287-2303.
- Simpson EL, Bieber T, Guttman-Yassky E, et al; for the SOLO1 and SOLO2 Investigators. Two phase 3 trials of dupilumab versus placebo in atopic dermatitis. N Engl J Med. 2016;375(24):2335-2348.Levy LL, Urban J, King BA. Treatment of recalcitrant atopic dermatitis with the oral Janus kinase inhibitor tofacitinib citrate. J Am Acad Dermatol. 2015;73(3):395-399.