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.

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