KEY POINTS FOR PRACTICE
• Treatment of atopic dermatitis with a midpotency topical corticosteroid once daily or a topical calcineurin inhibitor two to three times per week is safer and more effective for maintenance of remission than episodic treatment of flare-ups.
• Dilute bleach baths are beneficial for moderate to severe cases of atopic dermatitis.
• Systemic corticosteroids, elimination diets, and topical antimicrobial agents should be avoided in patients with atopic dermatitis .
From the AFP Editors
The American Academy of Allergy, Asthma and Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters updated guidelines for managing atopic dermatitis (eczema). Table 1 summarizes recommendations relevant to family physicians.
TABLE 1. Atopic Dermatitis Treatment—AAAAI/ACAAI Guideline Recommendations
| Treatment | Recommendation | Strength | Certainty |
|---|---|---|---|
| Topicals | Cases of any severity | ||
| Use over-the-counter moisturizers rather than prescription moisturizers | Conditional | Low | |
| Add a topical corticosteroid | Strong | High | |
| Add a topical calcineurin inhibitor | Strong | High | |
| If using mid- to high-potency topical treatment, apply once daily | Conditional | Moderate | |
| Use maintenance therapy with a low- to midpotency topical corticosteroid or topical calcineurin inhibitor | Strong | Moderate | |
| Avoid topical antimicrobials in patients with no clear signs of infection | Conditional | Very low | |
| Mild to moderate cases | |||
| Add crisaborole 2% ointment (available as brand Eucrisa) | Conditional | Moderate | |
| Dilute bleach baths | Moderate to severe cases | ||
| Use dilute bleach baths | Conditional | Low | |
| Mild cases | |||
| Avoid bleach baths | Conditional | Low | |
| Elimination diets | Cases of any severity | ||
| Avoid elimination diets | Conditional | Low |
Note: The full guideline for conditions for all recommendations, practical issues, implementation considerations, summary handouts, and additional information is available: https://www.annallergy.org/article/S1081-1206(23)01455-2/fulltext.
AAAAI/ACAAI = American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology.
Adapted with permission from Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2024 ;132(3):277.
EFFECTIVE THERAPIES
Recommended clinical practice includes ensuring the diagnosis is correct, discussing trigger avoidance, and supporting optimal medication and moisturizer use.
Moisturizers
Moisturizer therapy is critical for treatment of atopic dermatitis. Adherence is more important than the type of moisturizer used; therefore, the potential greater benefit of ointments compared with creams may be offset by patient intolerance. Systematic reviews have not shown a benefit of prescription moisturizers to justify the increased cost and inconvenience.
Topical Corticosteroids
Topical corticosteroids provide the largest improvements in patient-oriented outcomes and are strongly recommended when symptoms cannot be controlled with moisturizers alone. Randomized trials up to 6 weeks in duration show no significant increase in skin infections, atrophy, or other changes due to topical corticosteroids.
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