Atopic dermatitis Revised: February 17, 2012
Copyright Elsevier BV. All rights reserved.
Key points
Atopic dermatitis is a chronic skin disease characterized by barrier defects and allergic inflammation
Barrier defects predispose skin with atopic dermatitis to environmental triggers, infections, and,
subsequently, inflammation
Atopic dermatitis usually presents with dry skin, poorly defined erythema with infiltration, papules,
weeping in the acute stage, and lichenification in the chronic stage. It also may be accompanied by
viral, bacterial, or fungal superinfections
The diagnosis is primarily based on clinical presentation; additional laboratory tests are usually
unnecessary
Management of atopic dermatitis includes proper skin care, identification and eradication of
triggers, and anti-inflammatory treatment. Current treatment options include topical corticosteroids,
topical calcineurin inhibitors, antihistamines, barrier creams, and systemic corticosteroids
Certain adjunctive measures (eg, wet wraps, phototherapy) may also be beneficial
Treatment
Summary approach
The goals of treatment are relief of symptoms; prevention of flares and secondary infection; and
improvement of quality of life, including sleep, work, school, and social development
The first-line treatment for symptom relief is topical corticosteroids . Other options include topical
calcineurin inhibitors , barrier creams , antihistamines , and systemic corticosteroids
Certain adjunctive measures (eg, wet-wraps , phototherapy , psychotherapy ) also may be beneficial
There is no convincing evidence that various other therapies are effective in the treatment of atopic
dermatitis. Indeed, some of them have been proven to be ineffective by double-blind placebo-
controlled trials: specific allergen immunotherapy, omalizumab, montelukast, intravenous
immunoglobulin, probiotics, andMycobacterium vaccaevaccination
Complementary and alternative therapies (eg, silver- or antimicrobial-coated fabrics, vitamin D,
bleach baths, and various herbal and homeopathic preparations) also have been used in the
treatment of atopic dermatitis; however, large and/or randomized studies are needed to confirm
their efficacy
Medications
Topical corticosteroids
Indication
Hydrocortisone and desonide (low-potency corticosteroids) are considered first-line therapy for
atopic dermatitis
Triamcinolone and betamethasone (medium-potency corticosteroids) are necessary in more severe
disease
Fluocinonide (high-potency corticosteroid) should be used for brief periods to produce a rapid
reduction of inflammation, then the patient should be switched to a low- to moderate-potency
corticosteroid
Dose information
Adult
Betamethasone (0.05%-0.1%):
Apply a small amount to the affected area(s) twice a day
Treatment course: 1 to 2 weeks
Desonide (0.05%):
Apply a small amount to the affected area(s) every 6 to 12 hours
Treatment course: 1 to 2 weeks
Fluocinonide (0.05%-0.1%):
Apply a small amount to the affected area(s) every 6 to 12 hours
Treatment course: 1 to 2 weeks
Hydrocortisone (0.5%-2.5%):
Apply a small amount to the affected area(s) every 6 to 12 hours
Treatment course: 1 to 2 weeks
Triamcinolone (0.025%-0.5%):
Apply a small amount to the affected area(s) every 6 to 12 hours
Treatment course: 1 to 2 weeks
Pediatric
Low-potency corticosteroids (eg, hydrocortisone) may be used in children; however, moderate- to
high-potency corticosteroids should not be used in patients younger than 12 years. Children have a
greater susceptibility to topical corticosteroid-induced hypothalamic-pituitary-adrenal axis
suppression and Cushing syndrome than do mature patients because of a larger skin surface area to
body weight ratio
Major contraindications
Acute bronchospasm (triamcinolone)
Benzyl alcohol hypersensitivity (triamcinolone)
Corticosteroid hypersensitivity (betamethasone, fluocinonide, triamcinolone)
Fungal infection (hydrocortisone, triamcinolone)
Idiopathic thrombocytopenia (betamethasone,
Neonatal prematurity (triamcinolone)
Status asthmaticus (triamcinolone)
Comments
Common concerns among patients and parents regarding topical corticosteroids are skin thinning
and adverse effects on bones and growth. Frequently, topical corticosteroids are also misunderstood
to be the same as androgenic steroids. Therefore, it is important to clarify these issues
While explaining the benefits and adverse effects of topical corticosteroids to patients or parents, it is
important to make the distinction between systemic (oral or injection) corticosteroids and topical
corticosteroids. Topical corticosteroids are categorized in different strengths. An understanding of
the strengths and adverse effects of topical corticosteroids may improve compliance among patients
or parents or patients
Evidence
A systematic review of 11 randomized, controlled trials (RCTs) found that topical corticosteroids are
significantly more effective than placebo for the treatment of atopic dermatitis in children and
adults. [1] Level of evidence: 1
An RCT compared hydrocortisone buteprate cream (0.1%) versus placebo in patients with atopic
dermatitis. Patients treated with hydrocortisone buteprate had a significantly better outcome than
the controls. [2] Level of evidence: 1
Six double-blind, multicenter trials involving 485 patients (209 with atopic dermatitis; 276 with
plaque psoriasis) found that hydrocortisone valerate cream (0.2%) produced significant
improvement compared with the controls. [3] Level of evidence: 1
A small RCT compared betamethasone dipropionate with placebo in patients with atopic dermatitis;
94% had a good or excellent clinical response, compared with 13% of the controls. [4] Level of
evidence: 1
Another small RCT compared betamethasone dipropionate with placebo in patients with atopic
dermatitis. Betamethasone dipropionate produced a significant reduction in itch intensity compared
with placebo. [5] Level of evidence: 1
A systematic review assessed 31 trials including 8,019 subjects to compare the effectiveness of topical
pimecrolimus to two topical corticosteroids (triamcinolone and betamethasone), and to topical
tacrolimus. At 3 weeks, pimecrolimus patients suffered a greater incidence of burning skin and
patient withdrawals from the regimen than did patients treated with topical corticosteroids. Another
finding was that pimecrolimus was less effective than tacrolimus at 6 weeks' duration of therapy;
again with more withdrawals from the regimen, this time due to lack of efficacy. The review suggests
that topical pimecrolimus is not as effective as topical corticosteroids or tacrolimus in treatment of
atopic dermatitis. [6] Level of evidence: 1
References
Topical calcineurin inhibitors
Indication
Short-term treatment of moderate to severe atopic dermatitis
These medications also can be used to treat cases of atopic dermatitis resistant to steroids
Dose information
Tacrolimus
Adult:
Topical (0.03%-0.1%): Apply a small amount to the affected area(s) twice a day
Treatment course: 7 to 14 days; continue for 7 days after clearing of signs and symptoms
Pediatric:
Topical (0.03%): Apply a small amount to the affected area(s) twice a day
Treatment course: 7 to 14 days; continue for 7 days after clearing of signs and symptoms
Pimecrolimus
Topical (1%): Apply a small amount to the affected area(s) twice a day
Treatment course: 7 to 14 days
Safety and efficacy in children younger than 2 years have not been established; avoid use due to
potential increased risk of cancer
Major contraindications
Polyoxyethylated castor oil hypersensitivity (tacrolimus)
Comments
These medications have a black box warning from the U.S. Food and Drug Administration (FDA) on
a possible risk of cancer with continuous, long-term use. The warning is based on animal studies and
rare reports of skin cancer and lymphoma in patients who have used these medications. Long-term
studies are ongoing to confirm the safety of these medications. In the meantime, the FDA
recommends short-term use of these medications only on the affected areas
Topical calcineurin inhibitors do not decrease the synthesis of collagen in the skin, making them
useful for treating lesions on the face, eyelids, and other parts of the body with thin skin
If the rash does not improve within 6 weeks, patient should be re-examined to confirm the diagnosis
Evidence
A systematic review assessed 31 trials including 8,019 subjects to compare the effectiveness of topical
pimecrolimus to two topical corticosteroids (triamcinolone and betamethasone), and to topical
tacrolimus. At 3 weeks, pimecrolimus patients suffered a greater incidence of burning skin and
patient withdrawals from the regimen than did patients treated with topical corticosteroids. Another
finding was that pimecrolimus was less effective than tacrolimus at 6 weeks' duration of therapy;
again with more withdrawals from the regimen, this time due to lack of efficacy. The review suggests
that topical pimecrolimus is not as effective as topical corticosteroids or tacrolimus in treatment of
atopic dermatitis. [6] Level of evidence: 1
References
Antihistamines (sedating)
Indication
Treatment of symptoms associated with atopic dermatitis such as pruritus
Dose information
Diphenhydramine
Adult:
25 to 50 mg orally every 4 to 6 hours, when required
Maximum: 300 mg/d
Pediatric (>6 years):
12.5 to 25 mg every 4 to 6 hours, when required
Maximum: 300 mg/d
Comments
Antihistamines are used in the treatment of patients with atopic dermatitis mainly for their sedative
effect
Antihistamines also may be used to treat comorbid conditions of atopic dermatitis, such as allergic
rhinoconjunctivitis, dermatographism, urticaria, and sleep disruption. However, they are not
effective in treating pruritus associated with atopic dermatitis, as the itching in atopic dermatitis is
not solely secondary to histamine release
Long-acting and topical antihistamines are not useful in the treatment of atopic dermatitis because
of their minimal or lack of sedative effect
Barrier creams
Indication
Barrier creams, such as zinc oxide , are used for skin barrier repair
Dose information
Apply to the affected area(s) twice a day
Comments
Rather than providing the skin with an inert barrier like emollients do, these creams aim to repair
the skin barrier
They may be effective in mild atopic dermatitis, but there is inadequate evidence that they are
effective in moderate to severe disease
These nonsteroidal creams can be used by any age group
Evidence
An RCT compared a barrier cream to a mid-potency topical corticosteroid in the treatment of
moderate to severe atopic dermatitis. The barrier cream was shown to be as effective as the topical
corticosteroid in controlling atopic dermatitis after 28 days. These results have yet to be reproduced.
[7] Level of evidence: 3
References
Systemic corticosteroids
Indication
Systemic corticosteroids are used to treat severe and intractable atopic dermatitis
Dose information
Prednisone
Adult:
60 mg/d orally for 2 days, then 30 mg/d for 2 days, then 15 mg/d for 2 days, then 7.5 mg/d for 2
days, then stop
Treatment course: 8 days
Pediatric:
1 to 2 mg/kg/d orally in divided doses
Use of systemic corticosteroids in children is still controversial. In special cases, however, pediatric
patients may be given prednisone. Growth and development of pediatric patients should be carefully
observed during prolonged therapy
Major contraindications
Fungal infection
Comments
Systemic corticosteroids have been shown to be capable of reducing atopic dermatitis flares,
however, long-term or frequent intermittent use of these medications is associated with potential
adverse effects, including stunted growth, osteoporosis, cataract, adrenal suppression, and rebound
flare
Several corticosteroid regimens are available, such as alternate-day administration, intramuscular
injection, or pulsed high-dose treatment. The dosage and route of administration of systemic
steroids for atopic dermatitis, however, are still controversial. The dose should be tapered for 1 week
because there is a chance of a severe rebound effect after discontinuation of the treatment
Summary of evidence
Evidence
Topical corticosteroids and topical calcineurin inhibitors:
A systematic review of 11 randomized, controlled trials (RCTs) found that topical corticosteroids are
significantly more effective than placebo for the treatment of atopic dermatitis in children and
adults. [1] Level of evidence: 1
An RCT compared hydrocortisone buteprate cream (0.1%) versus placebo in patients with atopic
dermatitis. Patients treated with hydrocortisone buteprate had a significantly better outcome than
the controls. [2] Level of evidence: 1
Six double-blind, multicenter trials involving 485 patients (209 with atopic dermatitis; 276 with
plaque psoriasis) found that hydrocortisone valerate cream (0.2%) produced significant
improvement compared with the controls. [3] Level of evidence: 1
A small RCT compared betamethasone dipropionate with placebo in patients with atopic dermatitis;
94% had a good or excellent clinical response, compared with 13% of the controls. [4] Level of
evidence: 1
Another small RCT compared betamethasone dipropionate with placebo in patients with atopic
dermatitis. Betamethasone dipropionate produced a significant reduction in itch intensity compared
with placebo. [5] Level of evidence: 1
A systematic review assessed 31 trials including 8,019 subjects to compare the effectiveness of topical
pimecrolimus to two topical corticosteroids (triamcinolone and betamethasone), and to topical
tacrolimus. At 3 weeks, pimecrolimus patients suffered a greater incidence of burning skin and
patient withdrawals from the regimen than did patients treated with topical corticosteroids. Another
finding was that pimecrolimus was less effective than tacrolimus at 6 weeks' duration of therapy;
again with more withdrawals from the regimen, this time due to lack of efficacy. The review suggests
that topical pimecrolimus is not as effective as topical corticosteroids or tacrolimus in treatment of
atopic dermatitis. [6] Level of evidence: 1
Barrier creams:
An RCT compared a barrier cream to a mid-potency topical corticosteroid in the treatment of
moderate to severe atopic dermatitis. The barrier cream was shown to be as effective as the topical
corticosteroid in controlling atopic dermatitis after 28 days. These results have yet to be reproduced.
[7] Level of evidence: 3
Psychological and behavorial therapy:
A systemic review showed psychological intervention may have some beneficial effects on atopic
dermatitis, but this cannot be confirmed due to variability of the studies reviewed. Future studies
using psychological intervention should include more acceptable methods for subject randomization,
description, and measuring atopic dermatitis disease severity. [8] Level of evidence: 2
Treatment of secondary infections:
An RCT comparedS aureuscolonization in patients with atopic dermatitis treated with topical
corticosteroids versus similar patients treated with tacrolimus. The study, which included 60
patients, also randomized patients within the two treatment arms to cohorts with and without
adjunctive topical antibiotic therapy. The RCT found similar results with use of both types of primary
therapy, with or without topical antibiotics: reduction inS aureusnumbers, reduction in patient
symptom scores, and a small number of patients (2) developed resistant organisms. The results
suggest that topical anti-inflammatory therapy may serve as an alternative to topical antibiotic
therapy to improve skin inflammation from skin colonization byS aureus; a corollary suggestion is
that topical antibiotics might best be reserved for use in patients on a short-term basis when acute
infection arises. [9] Level of evidence: 2
References
References
Evidence references
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2. 2. Sears HW, Bailer JW, Yeadon A. Efficacy and safety of hydrocortisone buteprate 0.1% cream in
patients with atopic dermatitis. Clin Ther. 1997;19:710-9
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3. 3. Sefton J, Loder JS, Kyriakopoulos AA. Clinical evaluation of hydrocortisone valerate 0.2%
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4. 4. Vanderploeg DE. Betamethasone dipropionate ointment in the treatment of psoriasis and atopic
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5. 5. Wahlgren CF, Hägemark O, Bergström R, Hedin B. Evaluation of a new method of assessing
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7. 7. Sugarman JL, Parish LC. Efficacy of a lipid-based barrier repair formulation in moderate-to-severe
pediatric atopic dermatitis. J Drugs Dermatol. 2009;8:1106-11
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Guidelines
The National Collaborating Centre for Women's and Children's Health has produced the following:
Atopic eczema in children. Management of atopic eczema in children from birth up to the age of 12 years . London
(UK): National Institute for Health and Clinical Excellence (NICE); 2007. 39 p. (Clinical guideline;
no. 57)
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