Atopic Dermatitis
Severe atopic dermatitis management including topical therapy and advanced biologics.
Overview
Atopic dermatitis is a chronic, relapsing inflammatory skin condition that is the most severe form of eczema. It's characterized by intense itching, dry skin, and recurrent eczematous lesions. It's part of the atopic triad along with asthma and allergic rhinitis.
severity
mild
Localized lesions, minimal impact on daily life, responds well to topical therapy
moderate
More widespread involvement, moderate impact on quality of life, may require systemic therapy
severe
Extensive skin involvement, significant impact on sleep and daily activities, often requires systemic therapy or biologics
symptoms
- Intense itching (pruritus) - often the most distressing symptom
- Dry, scaly skin
- Red, inflamed patches
- Thickened, leathery skin (lichenification) from chronic scratching
- Cracked, bleeding skin
- Oozing or crusting during flare-ups
- Sleep disturbance due to itching
- Skin infections (bacterial, viral, fungal) due to broken skin barrier
evaluation
history
- Onset and duration of symptoms
- Family history of atopy
- Associated allergic conditions
- Impact on quality of life and sleep
- Previous treatments and responses
- Trigger identification
physical
Assessment of skin lesions, distribution, severity scoring (EASI, SCORAD), signs of infection
testing
- Allergy testing to identify triggers
- Consider food allergy evaluation in children
- Bacterial culture if infection is suspected
- Consider patch testing if contact allergy is suspected
treatment
topical Therapy
corticosteroids
- Use appropriate strength based on location and severity
- Low potency for face and sensitive areas
- Medium to high potency for body and severe cases
- Apply once or twice daily during flares
- Taper gradually to prevent rebound
calcineurin Inhibitors
- Tacrolimus (Protopic) or pimecrolimus (Elidel)
- Non-steroidal option for sensitive areas
- Can be used for maintenance therapy
- May cause burning sensation initially
other
- Crisaborole (Eucrisa) - phosphodiesterase-4 inhibitor
- Topical JAK inhibitors (ruxolitinib) - for limited areas
- Wet wrap therapy for severe flares
systemic
oral
- Oral antihistamines for itching (especially at night)
- Oral corticosteroids - short courses only for severe flares
- Cyclosporine - for severe, refractory cases
- Methotrexate or azathioprine - for long-term management in severe cases
biologics
- Dupilumab (Dupixent) - first-line biologic for moderate to severe atopic dermatitis
- Tralokinumab - anti-IL-13 monoclonal antibody
- Consider when topical therapy is insufficient or not tolerated
dupixent
indication
Moderate to severe atopic dermatitis not adequately controlled with topical therapy
dosing
Initial: 600mg, then 300mg every 2 weeks (adults) or weight-based dosing (children)
response
Most patients see improvement within 4-16 weeks
side Effects
Conjunctivitis, injection site reactions, headache
considerations
Can be used with topical therapy, monitor for eye symptoms
supportive
- Daily moisturization with fragrance-free products
- Bleach baths for bacterial colonization
- Wet wrap therapy
- Phototherapy (narrowband UVB) for widespread disease
- Stress management and psychological support
prevention
- Consistent moisturization routine
- Avoid known triggers
- Use gentle, fragrance-free products
- Maintain skin barrier with appropriate emollients
- Manage stress and anxiety
- Avoid excessive bathing and use lukewarm water
- Wear soft, breathable fabrics
referral
- Refer to dermatologist for severe or refractory cases
- Consider referral for biologic therapy evaluation
- Refer to allergist for comprehensive allergy evaluation
- Consider referral to psychologist or support groups for quality of life impact
prognosis
Atopic dermatitis is a chronic condition that can be effectively managed with appropriate therapy. While there's no cure, most patients can achieve good control with a combination of topical therapy, trigger avoidance, and in severe cases, systemic therapy or biologics. Quality of life can be significantly improved with proper management.
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