Atopic Dermatitis: Diagnosis and Treatment

 

Am Fam Physician. 2020 May 15;101(10):590-598.

  Patient information: A handout on this topic is available at https://familydoctor.org/condition/eczema-and-atopic-dermatitis.

Author disclosure: Dr. Bhardwaj does not have a formal relationship with any pharmaceutical company to disclose. The author and a public database revealed a food and beverage listing for crisaborole, but this was not a direct payment. Dr. Frazier has no financial affiliations to disclose.

Atopic dermatitis (atopic eczema) is a chronic relapsing and remitting inflammatory skin disease affecting one in 10 people in their lifetime. Atopic dermatitis is caused by a complex interaction of immune dysregulation, epidermal gene mutations, and environmental factors that disrupts the epidermis causing intensely pruritic skin lesions. Repeated scratching triggers a self-perpetuating itch-scratch cycle, which can have a significant impact on the patient's quality of life. The American Academy of Dermatology has created simple diagnostic criteria based on symptoms and physical examination findings. Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers. Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups. Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment. Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate. Antistaphylococcal antibiotics are effective in treating secondary skin infections. Oral antihistamines are not recommended because they do not reduce pruritus. Evidence is lacking to support the use of integrative medicine in the treatment of atopic dermatitis. Newer medications approved by the U.S. Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost prohibitive for most patients.

Atopic dermatitis, or atopic eczema, is a chronic relapsing and remitting inflammatory skin disease with a 10% lifetime prevalence.1 The disease is characterized primarily by scaly, pruritic, erythematous lesions located on flexural surfaces. Atopic dermatitis affects up to 12% of children and 7.2% of adults, leading to high health care use.2 Atopic dermatitis typically starts in childhood, with 60% of patients developing atopic dermatitis before one year of age and 90% by five years of age.3 Compared with children who do not have atopic dermatitis, those who have the condition are more likely to develop food and environmental allergies (15% vs. 4%), asthma (25% vs. 12%), and allergic rhinitis (34% vs. 14%).4 Patients with atopic dermatitis are also more likely to develop ear infections (27% vs. 22%), streptococcal pharyngitis (8% vs. 3%), and urinary tract infections (8% vs. 3%).5

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Emollients should be used as the primary therapy for atopic dermatitis flare-ups and maintenance.18

A

Systematic review of 77 studies

Once-daily bathing with lukewarm water that is limited to five to 10 minutes is recommended for patients with atopic dermatitis.17,25

C

Consensus guidelines

Topical corticosteroids should be used as first-line treatment for atopic dermatitis flare-ups.14,17,28

A

Systematic reviews and meta-analyses of RCTs

Topical calcineurin inhibitors may be used as first-line treatment for moderate to severe atopic dermatitis in combination with topical steroids.30,34

A

Systematic review and meta-analysis of eight RCTs; systematic review of 21 clinical trials

Ultraviolet B phototherapy should be used as second-line treatment for moderate to severe atopic dermatitis.28

B

Numerous lower-quality studies and one systematic review of nine studies

There is no high-quality evidence supporting oral antibiotics for prophylaxis, and they should be used only to treat secondary bacterial infections.28,39,40

B

Systematic review of 26 RCTs (n = 1,229); low-quality studies; one RCT


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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WINFRED FRAZIER, MD, MPH, FAAFP, is the associate program director and an assistant professor in the Department of Family Medicine at the University of Texas Medical Branch, Galveston....

NAMITA BHARDWAJ, MD, MS, CAQSM, is the director of sports medicine and an assistant professor with a joint appointment in the Department of Family Medicine and the Department of Orthopedics and Rehabilitation at the University of Texas Medical Branch.

Address correspondence to Winfred Frazier, MD, MPH, FAAFP, University of Texas Medical Branch, 301 University Blvd., Galveston, TX 77555 (email: wtfrazie@utmb.edu). Reprints are not available from the authors.

Author disclosure: Dr. Bhardwaj does not have a formal relationship with any pharmaceutical company to disclose. The author and a public database revealed a food and beverage listing for crisaborole, but this was not a direct payment. Dr. Frazier has no financial affiliations to disclose.

References

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1. Abuabara K, Magyari A, McCulloch CE, et al. Prevalence of atopic eczema among patients seen in primary care: data from the health improvement network. Ann Intern Med. 2019;170(5):354–356....

2. Strom MA, Silverberg JI. Utilization of preventive health care in adults and children with eczema. Am J Prev Med. 2016;50(2):e33–e44.

3. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338–351.

4. Silverberg JI, Simpson EL. Association between severe eczema in children and multiple comorbid conditions and increased healthcare utilization. Pediatr Allergy Immunol. 2013;24(5):476–486.

5. Serrano L, Patel KR, Silverberg JI. Association between atopic dermatitis and extracutaneous bacterial and mycobacterial infections: a systematic review and meta-analysis. J Am Acad Dermatol. 2019;80(4):904–912.

6. Boguniewicz M, Leung DY. Atopic dermatitis: a disease of altered skin barrier and immune dysregulation. Immunol Rev. 2011;242(1):233–246.

7. Al-Naqeeb J, Danner S, Fagnan LJ, et al. The burden of childhood atopic dermatitis in the primary care setting: a report from the Meta-LARC consortium. J Am Board Fam Med. 2019;32(2):191–200.

8. Brandt EB, Sivaprasad U. Th2 cytokines and atopic dermatitis. J Clin Cell Immunol. 2011;2(3):110.

9. Thomsen SF. Atopic dermatitis: natural history, diagnosis, and treatment. ISRN Allergy. 2014;2014:354250.

10. Stern RS, Nelson C. The diminishing role of the dermatologist in the office-based care of cutaneous diseases. J Am Acad Dermatol. 1993;29(5 pt 1):773–777.

11. Severity scoring of atopic dermatitis: the SCORAD index. Consensus report of the European Task Force on Atopic Dermatitis. Dermatology. 1993;186(1):23–31.

12. Berke R, Singh A, Guralnick M. Atopic dermatitis: an overview. Am Fam Physician. 2012;86(1):35–42. Accessed January 31, 2020. https://www.aafp.org/afp/2012/0701/p35.html

13. Lee J, Park CO, Lee KH. Specific immunotherapy in atopic dermatitis. Allergy Asthma Immunol Res. 2015;7(3):221–229.

14. Sidbury R, Tom WL, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014;71(6):1218–1233.

15. Chisolm SS, Taylor SL, Balkrishnan R, et al. Written action plans: potential for improving outcomes in children with atopic dermatitis. J Am Acad Dermatol. 2008;59(4):677–683.

16. Ersser SJ, Cowdell F, Latter S, et al. Psychological and educational interventions for atopic eczema in children. Cochrane Database Syst Rev. 2014;(1):CD004054.

17. 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.

18. Hon KL, Kung JSC, Ng WGG, et al. Emollient treatment of atopic dermatitis: latest evidence and clinical considerations. Drugs Context. 2018;7:212530. Accessed July 17, 2019. https://www.drugsincontext.com/emollient-treatment-of-atopic-dermatitis-latest-evidence-and-clinical-considerations/

19. van Zuuren EJ, Fedorowicz Z, Christensen R, et al. Emollients and moisturisers for eczema. Cochrane Database Syst Rev. 2017;(2):CD012119.

20. Hon KL, Ching GK, Leung TF, et al. Estimating emollient usage in patients with eczema. Clin Exp Dermatol. 2010;35(1):22–26.

21. Horimukai K, Morita K, Narita M, et al. Application of moisturizer to neonates prevents development of atopic dermatitis. J Allergy Clin Immunol. 2014;134(4):824–830.

22. Lowe AJ, Su JC, Allen KJ, et al. A randomized trial of a barrier lipid replacement strategy for the prevention of atopic dermatitis and allergic sensitization: the PEBBLES pilot study. Br J Dermatol. 2018;178(1):e19–e21.

23. Simpson EL, Chalmers JR, Hanifin JM, et al. Emollient enhancement of the skin barrier from birth offers effective atopic dermatitis prevention. J Allergy Clin Immunol. 2014;134(4):818–823.

24. Draelos ZD. An evaluation of prescription device moisturizers. J Cosmet Dermatol. 2009;8(1):40–43.

25. Schneider L, Tilles S, Lio P, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013;131(2):295-9.e1–27.

26. Huang JT, Abrams M, Tlougan B, et al. Treatment of Staphylococcus aureus colonization in atopic dermatitis decreases disease severity. Pediatrics. 2009;123(5):e808–e814.

27. Nicol NH, Boguniewicz M. Wet wrap therapy in moderate to severe atopic dermatitis. Immunol Allergy Clin North Am. 2017;37(1):123–139.

28. Sidbury R, Davis DM, Cohen DE, et al.; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71(2):327–349.

29. Tollefson MM, Bruckner AL; Section on Dermatology. Atopic dermatitis: skin-directed management. Pediatrics. 2014;134(6):e1735–e1744.

30. Schmitt J, von Kobyletzki L, Svensson A, et al. Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials. Br J Dermatol. 2011;164(2):415–428.

31. Hebert AA; Desonide Foam Phase III Clinical Study Group. Desonide foam 0.05%: safety in children as young as 3 months. J Am Acad Dermatol. 2008;59(2):334–340.

32. Walling HW, Swick BL. Update on the management of chronic eczema: new approaches and emerging treatment options. Clin Cosmet Investig Dermatol. 2010;3:99–117.

33. Dhar S, Seth J, Parikh D. Systemic side-effects of topical corticosteroids. Indian J Dermatol. 2014;59(5):460–464.

34. Siegfried EC, Jaworski JC, Kaiser JD, et al. Systematic review of published trials: long-term safety of topical corticosteroids and topical calcineurin inhibitors in pediatric patients with atopic dermatitis. BMC Pediatr. 2016;16:75.

35. Chen SL, Yan J, Wang FS. Two topical calcineurin inhibitors for the treatment of atopic dermatitis in pediatric patients: a meta-analysis of randomized clinical trials. J Dermatolog Treat. 2010;21(3):144–156.

36. Paller AS, Lebwohl M, Fleischer AB Jr, et al.; US/Canada Tacrolimus Ointment Study Group. Tacrolimus ointment is more effective than pimecrolimus cream with a similar safety profile in the treatment of atopic dermatitis: results from 3 randomized, comparative studies. J Am Acad Dermatol. 2005;52(5):810–822.

37. Thaçi D, Reitamo S, Gonzalez Ensenat MA, et al.; European Tacrolimus Ointment Study Group. Proactive disease management with 0.03% tacrolimus ointment for children with atopic dermatitis: results of a randomized, multicentre, comparative study. Br J Dermatol. 2008;159(6):1348–1356.

38. Eichenfield LF, Ahluwalia J, Waldman A, et al. Current guidelines for the evaluation and management of atopic dermatitis: a comparison of the Joint Task Force Practice Parameter and American Academy of Dermatology guidelines. J Allergy Clin Immunol. 2017;139(4S):S49–S57.

39. Francis NA, Ridd MJ, Thomas-Jones E, et al.; CREAM Trial Management Group. Oral and topical antibiotics for clinically infected eczema in children: a pragmatic randomized controlled trial in ambulatory care. Ann Fam Med. 2017;15(2):124–130.

40. George SM, Karanovic S, Harrison DA, et al. Interventions to reduce Staphylococcus aureus in the management of eczema. Cochrane Database Syst Rev. 2019;(10):CD003871.

41. Yang H, Wang J, Zhang X, et al. Application of topical phosphodiesterase 4 inhibitors in mild to moderate atopic dermatitis: a systematic review and meta-analysis [published correction appears in JAMA Dermatol. 2019;155(7):865]. JAMA Dermatol. 2019;155(5):585–593.

42. Goodrx. Accessed March 23, 2020. https://www.goodrx.com

43. Paller AS, Kabashima K, Bieber T. Therapeutic pipeline for atopic dermatitis: end of the drought? J Allergy Clin Immunol. 2017;140(3):633–643.

44. Ariëns LFM, Bakker DS, van der Schaft J, et al. Dupilumab in atopic dermatitis: rationale, latest evidence and place in therapy. Ther Adv Chronic Dis. 2018;9(9):159–170.

45. Bass AM, Anderson KL, Feldman SR. Interventions to increase treatment adherence in pediatric atopic dermatitis: a systematic review. J Clin Med. 2015;4(2):231–242.

46. Ellis RM, Koch LH, McGuire E, et al. Potential barriers to adherence in pediatric dermatology. Pediatr Dermatol. 2011;28(3):242–244.

47. Buys LM. Treatment options for atopic dermatitis. Am Fam Physician. 2007;75(4):523–528. Accessed January 31, 2020. https://www.aafp.org/afp/2007/0215/p523.html

48. Correale CE, Walker C, Murphy L, et al. Atopic dermatitis: a review of diagnosis and treatment. Am Fam Physician. 1999;60(4):1191–1198. Accessed January 31, 2020. https://www.aafp.org/afp/1999/0915/p1191.html

 

 

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