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

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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Clinical recommendationEvidence ratingComments

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


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


Consensus guidelines

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


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


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


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


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

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: 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.


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