1. Emollients (Moisturizers): Goal is to restore barrier function; “Soak & seal” use of emollients leads to a decrease in skin dryness, decrease in itching, protects the skin from irritants, improves appearance; daily lukewarm (not hot) bath 15– 20 mins, soap only where/ when necessary, pat (not rub) to dry skin, followed by application of ceramide-containing moisturizer like Cerave Cream. Other options are petrolatum-based emollient (hydrolatum, Aquaphor); Proper hydration decreases need for topical steroid by about 50%.
“Xerosis (skin dryness) is a common finding in atopic dermatitis, and many patients attest that control of their xerosis mirrors control of their dermatitis. Consequently, patients with atopic dermatitis should liberally apply emollients to the entire body whether or not active symptoms are present.”
“Moisturizers help retain and replenish epidermal moisture. However, not all emollients are the same. In general, emollients with high oil content and low water content are recommended. Thick creams that are low in water (e.g., Cetaphil, Eucerin) or ointments (e.g., Aquaphor, petroleum jelly) are preferred. Although their superiority over conventional emollients is not well established, a new generation of barrier-repair moisturizers are now available and are designed to add ceramide lipids to skin in addition to hydration (e.g., Cerave, Restoraderm). To avoid xerosis, physicians should recommend that patients shower with warm instead of hot water and use an emollient wash while showering.” AAFP
2. Topical corticosteroids: first-line topical tx for mod / severe AD; use lowest effective potency at lowest freq possible to prevent side effects; ointments preferred (most hydrating); intermittent use (twice weekly) can decrease the potential for relapse. Side effects: Irreversible atrophy, striae. E.g. Triamcinolone 0.1% for body. Desonide cream for face and sensitive areas.
3. Antipruritics: Antihistamines PRN day (nonsedating) ± night, esp if significant sleep disruption, allergic dermatographism, or AR
4. Treat Staph colonization: For severe cases, twice weekly dilute bleach baths (0.5 cup of 6% bleach to full bathtub, immerse × 5–10 mins, then rinse, pat dry, emollients) plus intranasal mupirocin ointment 5 consecutive d/ mo; oral antibiotic not recommended for routine use.
When to Refer: Severe or refractory disease, consideration of PO corticosteroids; erythroderma
• Consideration of topical calcineurin inhibitors, phototherapy, immunomodulators (CsA, MMF, MTX)
• Widespread bacterial superinfection or eczema herpeticum = dermatologic emergency: Prompt tx w/ abx or antivirals; may need ED/ hospitalization