Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute flare

1st line – emollient

Back
ACUTE
|
acute flare
1st line – 

emollient

Emollients rehydrate and improve the barrier function of the skin, and are an essential component of the daily skincare regimen for all patients.​[80][85]​​​​​​​​ [ Cochrane Clinical Answers logo ] ​​​ Emollients alone may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​ 

Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.

By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).[50]​​​

There is insufficient evidence to determine whether one emollient is better than another.[80][85]​​​​​ However, increased lipid content is associated with improved hydration of the skin. Petrolatum effectively prevents water loss and may reduce T-cell-associated inflammation in atopic skin.[86]  

In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85][87]​​ Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[85]​​

American Academy of Dermatology guidelines make a conditional recommendation for the use of wet wrap therapy in adults with moderate to severe atopic dermatitis experiencing a flare, caveating that most data are from pediatric populations. They note that wet wrap therapy requires increased time and effort, as well as patient education, so the benefit in mild disease relative to the effort required is questionable.[85]

UK guidelines recommend that occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45] Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days). Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled. The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]

Consider – topical corticosteroid

Back
ACUTE
|
acute flare
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroids reduce inflammation and pruritus. They may be used in patients not controlled with emollients alone. Intermittent use on affected areas may be sufficient to control symptoms.

Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[85]​ Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[88] If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.

While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat flares.[89]

The potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45][85]​​ Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very high-potency topical corticosteroids can be effective in short courses for controlling flares of severe atopic dermatitis in adults but should not be used for children without specialist advice.

A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected.[45] Once the flare has settled, treating problem areas with topical corticosteroids twice weekly to prevent further flares could be considered for patients who experience frequent flares (e.g., 2 or 3 per month).[45][85][89]​​​ Available data indicate fewer relapses and increased time between relapses with this strategy.[85]

Parents and caregivers may express concern regarding the use of topical corticosteroids and be reluctant to use these agents on their child's skin.[90][91]​​​ Ensuring that caregivers are aware of the mechanism of action of the corticosteroid, its efficacy and safety, and how to reduce the dose may contribute to improved treatment.[92]​ Patients can be informed that the FDA has approved several formulations of topical corticosteroid for infants ≥3 months of age who have atopic dermatitis.

The incidence of adverse events with topical corticosteroids is low.[85] Using the lowest-potency formulation that effectively treats a patient's dermatitis will help to minimize these. Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible. Hydrocortisone butyrate lotion has been shown to be safe and effective in children ages over 3 months.[93]

Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85] The related concepts of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) are less clearly characterized in the literature, with low strength of evidence reported in systematic reviews.[94][95]

Systemic adverse effects associated with topical corticosteroid use are rare, but may include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[85][96]​​​ These events usually occur in patients using large amounts of potent corticosteroids continuously for prolonged periods.[85] An association with cataracts or glaucoma is unclear, but minimizing periocular corticosteroid use is advised.[85]

Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[97] 

Options include:[98] 

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, halobetasol, diflorasone.

Topical corticosteroid formulations included here are examples only. Formulations may vary and you should consult your local drug formulary for more information on available formulations and doses.

Primary options

hydrocortisone butyrate topical: (0.1%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily for up to 4 weeks

OR

fluticasone propionate topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

triamcinolone topical: (0.05% to 0.1%) children and adults: apply sparingly to the affected area(s) twice to four times daily

OR

fluocinolone topical: (0.025%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice to four times daily

OR

mometasone topical: (0.1%) children ≥2 years of age and adults: apply sparingly to the affected area(s) once daily

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

desoximetasone topical: (0.05 to 0.25%) children ≥10 years of age and adults: apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

halobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) once or twice daily for up to 2 weeks, maximum 50 g/week

OR

diflorasone topical: (0.05%) adults: apply sparingly to the affected area(s) twice to four times daily

Consider – topical calcineurin inhibitor

Back
ACUTE
|
acute flare
Consider – 

topical calcineurin inhibitor

Treatment recommended for SOME patients in selected patient group

Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) can be used as an alternative to, or in combination with, topical corticosteroids for acute flares. They are particularly useful for facial atopic dermatitis with eyelid involvement.[85]​​ Topical calcineurin inhibitors should be used by physicians who are experienced in treating atopic dermatitis.

In one meta-analysis, calcineurin inhibitors were found to be the most effective topical agent in lessening pruritus associated with atopic dermatitis.[99]​ Another systematic review of 20 trials reported that tacrolimus (0.1%) was more effective than pimecrolimus, tacrolimus (0.03%), and low-potency corticosteroids for the treatment of atopic dermatitis.[100]​ In addition, tacrolimus (0.03%) was found to be superior to mild corticosteroids and pimecrolimus.[100] [ Cochrane Clinical Answers logo ] ​​

The most common adverse reactions seen with the use of calcineurin inhibitors are erythema, pruritus and skin irritation, or skin burning at the site of application.[50]

There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been confirmed, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.

A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[101]​ The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[101] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or topical pimecrolimus significantly increased the risk of lymphoma.[102]​ Subgroup analyses showed that both topical tacrolimus and topical pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[102]

Primary options

pimecrolimus topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily

OR

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) adults: apply to the affected area(s) twice daily

Consider – topical crisaborole

Back
ACUTE
|
acute flare
Consider – 

topical crisaborole

Treatment recommended for SOME patients in selected patient group

Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, is approved in the US for flares or maintenance treatment of mild to moderate atopic dermatitis in patients ages 3 months and older.[85] It does not have marketing authorization in the UK or Europe. Crisaborole improves disease severity and pruritus.[103][104][105]

Adverse effects include application-site reactions (pain, burning, pruritus, stinging, and erythema); treatment-related adverse reactions are typically mild to moderate.[104]

Crisaborole is typically used twice daily; however, one randomized controlled trial found that, compared with ointment containing no drug, long-term maintenance treatment with once-daily application resulted in delayed onset of first flare, greater number of flare-free days, and decreased number of flares in patients who had previously responded to twice-daily application, suggesting that once-daily treatment could be a potential long-term maintenance treatment option.[106]

Primary options

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily; consider reducing to once daily after clinical effect achieved

Consider – topical ruxolitinib

Back
ACUTE
|
acute flare
Consider – 

topical ruxolitinib

Treatment recommended for SOME patients in selected patient group

Topical Janus kinase (JAK) inhibitors have the potential to reduce inflammation and improve pruritus, without the skin thinning associated with topical corticosteroid use.[107][108][109][110]

Topical ruxolitinib is approved in the US for the short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis in immunocompetent patients older than 12 years whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.[111]​ Topical ruxolitinib is not currently approved for this indication in Europe.[50]

US guidelines differ in their recommendations regarding ruxolitinib. American Academy of Dermatology guidelines include it in their treatment algorithm, whereas American College of Allergy, Asthma and Immunology guidelines do not recommend it, citing concerns about the potential for serious adverse effects due to systemic absorption.[75][85][111]​​​​​ The body surface area limitation for topical ruxolitinib is up to 20% due to these safety concerns.[85][112]​​​

Primary options

ruxolitinib topical: (1.5%) children ≥12 years of age and adults: apply to the affected area(s) twice daily, maximum 60 g/week or 100 g/2 weeks; treatment area should not exceed 20% body surface area

Consider – topical or oral antibiotic therapy

Back
ACUTE
|
acute flare
Consider – 

topical or oral antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Oral antibiotics should only be used when there is evidence of cutaneous infection (e.g., cellulitis, impetigo).[50][81]​ A topical antibiotic should be considered first if the infection is limited.[113]

American Academy of Dermatology guidelines conditionally recommend against the use of topical antimicrobials and topical antiseptics to treat uninfected atopic dermatitis in adults.[85] For patients with moderate to severe atopic dermatitis and clinical signs of secondary bacterial infection, bleach baths or the use of topical sodium hypochlorite may be suggested to reduce disease severity.[85]

Antibiotic choice depends on cultures and sensitivities and local guidelines.

2nd line – systemic immunosuppressive agent

Back
ACUTE
|
acute flare
2nd line – 

systemic immunosuppressive agent

In an acute severe flare, a short course of an oral corticosteroid or cyclosporine may be required due to their rapid onset of action. The patient may be switched to another agent once disease is controlled. Systemic corticosteroids are not recommended for the long-term treatment of atopic dermatitis due to their adverse effects, although guidelines concede that clinicians might consider short courses in limited circumstances, such as when no other options are available, or as a bridge to other long-term therapies.[50][81]​​​

Primary options

prednisone: children: consult specialist for guidance on dose; adults: 5-60 mg/day orally

OR

cyclosporine modified: children: consult specialist for guidance on dose; adults: 3-5 mg/kg/day orally given in 2 divided doses initially, adjust dose according to response

Plus – emollient

Back
ACUTE
|
acute flare
Plus – 

emollient

Treatment recommended for ALL patients in selected patient group

Emollients rehydrate and improve the barrier function of the skin, and are an essential component of the daily skincare regimen for all patients.[80][85]​​​​​ [ Cochrane Clinical Answers logo ] ​​​ Emollients alone may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​ 

Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.

By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).[50]​​​

There is insufficient evidence to determine whether one emollient is better than another.[80][85]​​​​ However, increased lipid content is associated with improved hydration of the skin. Petrolatum effectively prevents water loss and may reduce T-cell-associated inflammation in atopic skin.[86]  

In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.​[85][87]​ Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[85]​​

American Academy of Dermatology guidelines make a conditional recommendation for the use of wet wrap therapy in adults with moderate to severe atopic dermatitis experiencing a flare, caveating that most data are from pediatric populations. They note that wet wrap therapy requires increased time and effort, as well as patient education, so the benefit in mild disease relative to the effort required is questionable.[85]

UK guidelines recommend that occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]​ Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days). Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled. The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]

Consider – topical corticosteroid

Back
ACUTE
|
acute flare
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroids reduce inflammation and pruritus. Intermittent use on affected areas may be sufficient to control symptoms.

Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[85]​ Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[88] If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.

While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat flares.[89]

The potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45][85]​ Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very high-potency topical corticosteroids can be effective in short courses for controlling flares of severe atopic dermatitis in adults but should not be used for children without specialist advice.

A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected.[45] Once the flare has settled, treating problem areas with topical corticosteroids twice weekly to prevent further flares could be considered for patients who experience frequent flares (e.g., 2 or 3 per month).[45][89]​​​ Available data indicate fewer relapses and increased time between relapses with this strategy.[85]

Parents and caregivers may express concern regarding the use of topical corticosteroids and be reluctant to use these agents on their child's skin.[90][91]​ Ensuring that caregivers are aware of the mechanism of action of the corticosteroid, its efficacy and safety, and how to reduce the dose may contribute to improved treatment.[92]​ Patients can be informed that the FDA has approved several formulations of topical corticosteroid for infants ≥3 months of age who have atopic dermatitis.

The incidence of adverse events with topical corticosteroids is low.[85] Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize these. Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible. Hydrocortisone butyrate lotion has been shown to be safe and effective in children ages over 3 months.[93]

Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85] The related concepts of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) are less clearly characterized in the literature, with low strength of evidence reported in systematic reviews.[94][95]

Systemic adverse effects associated with topical corticosteroid use are rare, but may include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[85][96]​​ These events usually occur in patients using large amounts of potent corticosteroids continuously for prolonged periods.[85]

Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[97] 

Options include:[98] 

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, halobetasol, diflorasone.

Topical corticosteroid formulations included here are examples only. Formulations may vary and you should consult your local drug formulary for more information on available formulations and doses.

Primary options

hydrocortisone butyrate topical: (0.1%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily for up to 4 weeks

OR

fluticasone propionate topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

triamcinolone topical: (0.05% to 0.1%) children and adults: apply sparingly to the affected area(s) twice to four times daily

OR

fluocinolone topical: (0.025%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice to four times daily

OR

mometasone topical: (0.1%) children ≥2 years of age and adults: apply sparingly to the affected area(s) once daily

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

desoximetasone topical: (0.05 to 0.25%) children ≥10 years of age and adults: apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

halobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

diflorasone topical: (0.05%) adults: apply sparingly to the affected area(s) twice to four times daily

Consider – topical calcineurin inhibitor

Back
ACUTE
|
acute flare
Consider – 

topical calcineurin inhibitor

Treatment recommended for SOME patients in selected patient group

Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) can be used as an alternative to, or in combination with, topical corticosteroids for acute flares. They are particularly useful for facial atopic dermatitis with eyelid involvement.[85]​​ Topical calcineurin inhibitors should be used by physicians who are experienced in treating atopic dermatitis.

In one meta-analysis, calcineurin inhibitors were found to be the most effective topical agent in lessening pruritus associated with atopic dermatitis.[99]​ Another systematic review of 20 trials reported that tacrolimus (0.1%) was more effective than pimecrolimus, tacrolimus (0.03%), and low-potency corticosteroids for the treatment of atopic dermatitis.[100]​ In addition, tacrolimus (0.03%) was found to be superior to mild corticosteroids and pimecrolimus.[100] [ Cochrane Clinical Answers logo ] ​​

The most common adverse reactions seen with the use of calcineurin inhibitors are erythema, pruritus and skin irritation, or skin burning at the site of application.[50]

There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been confirmed, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.

A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[101]​ The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[101] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or topical pimecrolimus significantly increased the risk of lymphoma.[102]​ Subgroup analyses showed that both topical tacrolimus and topical pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[102]

Primary options

pimecrolimus topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily

OR

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) adults: apply to the affected area(s) twice daily

Consider – topical crisaborole

Back
ACUTE
|
acute flare
Consider – 

topical crisaborole

Treatment recommended for SOME patients in selected patient group

Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, is approved in the US for flares or maintenance treatment of mild to moderate atopic dermatitis in patients ages 3 months and older.[85] It does not have marketing authorization in the UK or Europe. Crisaborole improves disease severity and pruritus.[103][104][105]

Adverse effects include application-site reactions (pain, burning, pruritus, stinging, and erythema); treatment-related adverse reactions are typically mild to moderate.[104]

Crisaborole is typically used twice daily; however, one randomized controlled trial found that long-term maintenance treatment with once-daily application resulted in delayed onset of first flare, greater number of flare-free days, and decreased number of flares compared to ointment with no drug in patients who had previously responded to twice-daily application, suggesting that once-daily treatment could be a potential long-term maintenance treatment option.[106]

Primary options

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily; consider reducing to once daily after clinical effect achieved

Consider – topical or oral antibiotic therapy

Back
ACUTE
|
acute flare
Consider – 

topical or oral antibiotic therapy

Treatment recommended for SOME patients in selected patient group

Oral antibiotics should only be used when there is evidence of cutaneous infection (e.g., cellulitis, impetigo).[50][81]​ A topical antibiotic should be considered first if the infection is limited.[113]

American Academy of Dermatology guidelines conditionally recommend against the use of topical antimicrobials and topical antiseptics to treat uninfected atopic dermatitis in adults.[85] For patients with moderate to severe atopic dermatitis and clinical signs of secondary bacterial infection, bleach baths or the use of topical sodium hypochlorite may be suggested to reduce disease severity.[85]

Antibiotic choice depends on cultures and sensitivities and local guidelines.

ONGOING

chronic or relapsing disease

1st line – emollient

Back
ONGOING
|
chronic or relapsing disease
1st line – 

emollient

Emollients rehydrate and improve the barrier function of the skin, and are an essential component of the daily skincare regimen for all patients.[80][85]​​​​​ [ Cochrane Clinical Answers logo ] ​​​ Emollients alone may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​ 

Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.

By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).[50]​​​

There is insufficient evidence to determine whether one emollient is better than another.[80][85]​​​​ However, increased lipid content is associated with improved hydration of the skin. Petrolatum effectively prevents water loss and may reduce T-cell-associated inflammation in atopic skin.[86]  

In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85][87] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[85]​​

American Academy of Dermatology guidelines make a conditional recommendation for the use of wet wrap therapy in adults with moderate to severe atopic dermatitis experiencing a flare, caveating that most data are from pediatric populations. They note that wet wrap therapy requires increased time and effort, as well as patient education, so the benefit in mild disease relative to the effort required is questionable.[85]

UK guidelines recommend that occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]​ Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days). Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled. The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]

Consider – topical corticosteroid

Back
ONGOING
|
chronic or relapsing disease
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroids reduce inflammation and pruritus. They may be used in patients not controlled with emollients alone. Using the lowest-potency topical corticosteroid formulation that effectively treats a patient's dermatitis will help to minimize adverse effects.

Topical corticosteroids may be used in combination with emollients.[85]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​​

Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[85]​ Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[88]​ If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.

While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat flares.[89]

The potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45][85]​​ Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very high-potency topical corticosteroids can be effective in short courses for controlling flares of severe atopic dermatitis in adults but should not be used for children without specialist advice.

A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected.[45] Once the flare has settled, treating problem areas with topical corticosteroids twice weekly to prevent further flares could be considered for patients who experience frequent flares (e.g., 2 or 3 per month).[45][85][89]​​ Available data indicate fewer relapses and increased time between relapses with this strategy.[85]

Parents and caregivers may express concern regarding the use of topical corticosteroids and be reluctant to use these agents on their child's skin.[90][91]​ Ensuring that caregivers are aware of the mechanism of action of the corticosteroid, its efficacy and safety, and how to reduce the dose may contribute to improved treatment.[92]​ Patients can be informed that the FDA has approved several formulations of topical corticosteroid for infants ≥3 months of age who have atopic dermatitis.

The incidence of adverse events with topical corticosteroids is low.[85] Using the lowest-potency formulation that effectively treats a patient's dermatitis will help to minimize these. Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible. Hydrocortisone butyrate lotion has been shown to be safe and effective in children ages over 3 months.[93]

Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85] The related concepts of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) are less clearly characterized in the literature, with low strength of evidence reported in systematic reviews.[94][95]

Systemic adverse effects associated with topical corticosteroid use are rare, but may include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[85][96]​ These events usually occur in patients using large amounts of potent corticosteroids continuously for prolonged periods.[85] An association with cataracts or glaucoma is unclear, but minimizing periocular corticosteroid use is advised.[85]

Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[97]​ While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily dosing by the FDA. 

Options include:[98] 

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, halobetasol, diflorasone.

Topical corticosteroid formulations included here are examples only. Formulations may vary and you should consult your local drug formulary for more information on available formulations and doses.

Primary options

hydrocortisone butyrate topical: (0.1%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily for up to 4 weeks

OR

fluticasone propionate topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

triamcinolone topical: (0.05% to 0.1%) children and adults: apply sparingly to the affected area(s) twice to four times daily

OR

fluocinolone topical: (0.025%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice to four times daily

OR

mometasone topical: (0.1%) children ≥2 years of age and adults: apply sparingly to the affected area(s) once daily

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

desoximetasone topical: (0.05 to 0.25%) children ≥10 years of age and adults: apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

halobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) once or twice daily for up to 2 weeks, maximum 50 g/week

OR

diflorasone topical: (0.05%) adults: apply sparingly to the affected area(s) twice to four times daily

Consider – topical calcineurin inhibitor

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chronic or relapsing disease
Consider – 

topical calcineurin inhibitor

Treatment recommended for SOME patients in selected patient group

If there is a need for daily topical corticosteroids to maintain control of atopic dermatitis (and particularly if there is facial atopic dermatitis with eyelid involvement), a topical calcineurin inhibitor (e.g., pimecrolimus, tacrolimus) may be considered, either as monotherapy or in combination with a topical corticosteroid.[85]​ Topical calcineurin inhibitors should be used by physicians who are experienced in treating atopic dermatitis.

In one meta-analysis, calcineurin inhibitors were found to be the most effective topical agent in lessening pruritus associated with atopic dermatitis.[99] Another systematic review of 20 trials reported that tacrolimus (0.1%) was more effective than pimecrolimus, tacrolimus (0.03%), and low-potency corticosteroids for the treatment of atopic dermatitis.[100] In addition, tacrolimus (0.03%) was found to be superior to mild corticosteroids and pimecrolimus.[100] [ Cochrane Clinical Answers logo ] ​​

The most common adverse reactions seen with the use of calcineurin inhibitors are erythema, pruritus and skin irritation, or skin burning at the site of application.[50]

There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been confirmed, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.

A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[101] The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[101] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or topical pimecrolimus significantly increased the risk of lymphoma.[102] Subgroup analyses showed that both topical tacrolimus and topical pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[102] 

Primary options

pimecrolimus topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily

Secondary options

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) adults: apply to the affected area(s) twice daily

Consider – topical crisaborole

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chronic or relapsing disease
Consider – 

topical crisaborole

Treatment recommended for SOME patients in selected patient group

Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, is approved in the US for maintenance treatment of mild to moderate atopic dermatitis in patients ages 3 months and older.[85]​ It does not have marketing authorization in the UK or Europe. Crisaborole improves disease severity and pruritus in patients with mild to moderate atopic dermatitis.[103][104][105]​​​​

Adverse effects include application-site reactions (pain, burning, pruritus, stinging, and erythema); treatment-related adverse reactions are typically mild to moderate.[104]

Crisaborole is typically used twice daily; however, one randomized controlled trial found that long-term maintenance treatment with once-daily application resulted in delayed onset of first flare, greater number of flare-free days, and decreased number of flares compared to ointment with no drug in patients who had previously responded to twice-daily application, suggesting that once-daily treatment could be a potential long-term maintenance treatment option.[106]

Primary options

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily; consider reducing to once daily after clinical effect achieved

Consider – topical ruxolitinib

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chronic or relapsing disease
Consider – 

topical ruxolitinib

Treatment recommended for SOME patients in selected patient group

Topical Janus kinase (JAK) inhibitors have the potential to reduce inflammation and improve pruritus, without the skin thinning associated with topical corticosteroid use.[107][108][109][110]

Topical ruxolitinib is approved in the US for the short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis in immunocompetent patients older than 12 years whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.[111]​ Topical ruxolitinib is not currently approved for this indication in Europe.[50]

US guidelines differ in their recommendations regarding ruxolitinib. American Academy of Dermatology guidelines include it in their treatment algorithm, whereas American College of Allergy, Asthma and Immunology guidelines do not recommend it, citing concerns about the potential for serious adverse effects due to systemic absorption.[75][85][111]​​​​ The body surface area limitation for topical ruxolitinib is up to 20% due to these safety concerns.[85][112]

Primary options

ruxolitinib topical: (1.5%) children ≥12 years of age and adults: apply to the affected area(s) twice daily, maximum 60 g/week or 100 g/2 weeks; treatment area should not exceed 20% body surface area

2nd line – systemic immunosuppressive agent

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chronic or relapsing disease
2nd line – 

systemic immunosuppressive agent

The International Eczema Council advises starting systemic therapy if: the patient has moderate to severe atopic dermatitis that has not responded to topical therapy and phototherapy (disease severity measured using a score such as the Eczema Area and Severity Index [EASI]); adequate education has been provided, including discussion of possible steroid phobia; infection has been excluded and allergy has been considered including, if indicated, patch testing or referral to allergy services.[117]

Systemic therapies must be used under the guidance of a specialist.[118]​ Include assessment of severity and quality of life, while considering the individual's general health status, psychological needs, and personal attitudes toward systemic therapies, when deciding whether to start systemic medication.[117]

Systemic treatments can be divided into: biologic agents (e.g., dupilumab, tralokinumab); oral Janus kinase (JAK) inhibitors (e.g., abrocitinib, upadacitinib, baricitinib); and conventional systemic treatments (e.g., cyclosporine, methotrexate, azathioprine, mycophenolate).

Choice of therapy is determined by onset and severity of symptoms (e.g., oral cyclosporine may be used in an acute, severe flare due to rapid onset of action and the patient may then be switched to another agent when disease has been controlled), sex (methotrexate should be avoided in women of childbearing age planning to conceive), comorbidities (cyclosporine is avoided in renal impairment, while methotrexate is avoided if liver fibrosis is present or in renal impairment), and patient choice.

US and European guidelines recommend dupilumab, a monoclonal antibody that blocks interleukin (IL)-4 and IL-13, as a suitable first-line treatment option for most patients who require systemic treatment.[50][81]​​ It is approved for the treatment of moderate to severe atopic dermatitis in adults and children ≥6 months of age whose disease is not adequately controlled with topical prescription therapies (or when those therapies are not advisable).[50][81] The efficacy of dupilumab for moderate to severe atopic dermatitis is supported by data from large randomized trials.[120][121][122]​ Clinical response is seen in 4-6 weeks.[126]​ Results from one cohort study indicate that patient-reported benefits of rapid and sustained disease may be maintained for up to 12 months.[127]​ Adverse effects include conjunctivitis, injection-site reactions, upper respiratory tract infections, arthralgia, and oral herpes.[126][128]​ For most patients, conjunctivitis is self-limited and can be managed conservatively.[81] No laboratory monitoring is required before initiation or during treatment.[50][81]

Tralokinumab, a monoclonal antibody that blocks IL-13, is approved as an alternative first-line treatment option.[50][81] It is approved for the treatment of moderate to severe atopic dermatitis in patients ages 12 years and older whose disease is not adequately controlled with topical prescription therapies (or when those therapies are not advisable).[50][81] Clinical response is seen in 4-8 weeks.[126]​ No major safety concerns have been identified in clinical trials. Conjunctivitis is a common adverse effect (though appears to be less of a problem than with dupilumab); for most patients it is self-limited and can be managed conservatively.[50][81] Other reported adverse effects include viral upper respiratory tract infections and injection-site reactions.[134]​ No laboratory monitoring is required before initiation or during treatment.[50][81]

Oral JAK inhibitors can be used second-line in patients with moderate to severe atopic dermatitis who are refractory to (or unable to have) other systemic therapies.[81] Evidence from systematic reviews demonstrates that JAK inhibitors are effective for treating atopic dermatitis, significantly reducing EASI and pruritus scores, and improving quality of life.[135][136]​ Abrocitinib and upadacitinib are selective JAK1 inhibitors that are approved as a second-line treatment for adults with moderate to severe atopic dermatitis who have not responded to other systemic therapies (or when use of those therapies is inadvisable).[50][81] Baricitinib, a JAK1/2 inhibitor, is an alternative second-line systemic treatment for adults and children ages ≥2 years with moderate to severe atopic dermatitis and is approved for use in Europe but not the US.[50][81] No head-to-head clinical trials have been done; however, network meta-analysis suggests baricitinib is less efficacious than upadacitinib and abrocitinib.[133]​ Adverse events associated with JAK inhibitors include an increased risk of serious and opportunistic infections (including herpes zoster), cardiac events, cancer, blood clots, and death. The European Medicines Agency advises that JAK inhibitors should only be used in the following patient groups when there are no suitable alternatives: those ages 65 years and older; those at increased risk of major cardiovascular problems (such as heart attack or stroke); those who smoke or who have a long past smoking history; and those at increased risk of cancer. Cautious use is also recommended in patients with other known risk factors for venous thromboembolism.[143]​ The Food and Drug Administration has issued similar recommendations in the US.[144]​ Because of potential safety concerns, it is recommended that these medications be started at lower doses, particularly in older adults, a population considered to be at higher risk for adverse events.[50] Shingles vaccination is recommended before initiating a JAK inhibitor, particularly in older patients. Any other required live vaccines should also be administered prior to commencing treatment.[81] Regular monitoring of laboratory tests is required.[81]

Cyclosporine is very effective for atopic dermatitis in both children and adults, with a better tolerability in children.[50] It is licensed for adult atopic dermatitis in some countries but use is off-label in the US.[50][81] Due to its rapid onset of action, short courses of cyclosporine (2 weeks) may be beneficial in controlling particularly treatment-resistant disease, and allow for the introduction of maintenance regimens. Long-term efficacy has also been reported in children and adults.[145][146][147]​ It is associated with increased risk of hypertension and renal dysfunction.[19][64][148]​​ US guidelines advise that it is not suitable for long-term use, as the potential for renal damage increases with cumulative dose. Treatment should be limited to no more than 12 months (and preferably less) and regular monitoring with blood pressure checks and laboratory tests is required.[50][81]

Methotrexate, a folic acid antagonist with anti-inflammatory effects, is an alternative systemic treatment. Use of methotrexate for atopic dermatitis is off-label in the US and Europe.[50][81] Onset of action takes several weeks and peak efficacy is seen after months (although speed of treatment effect onset depends on the dosing regimen).[50] Oral and subcutaneous delivery are considered equivalent options of administration. For patients in whom oral methotrexate is ineffective or poorly tolerated, a trial of subcutaneous administration is an alternative; subcutaneous delivery increases bioavailability and tolerability, as well as adherence, compared with oral treatment.[50][152]​ Adverse effects include nausea, elevated liver enzymes, and occasionally pancytopenia or hepatic or pulmonary toxicity.[153][154][155]​ Regular monitoring of laboratory tests is required.[81] It can affect fertility and is teratogenic; women of childbearing potential should use effective contraception. The same recommendation is made for men treated with methotrexate who live with a woman of childbearing potential.[50] Concomitant use of cyclosporine is a relative contraindication.[50]

Azathioprine is used off-label for atopic dermatitis. Efficacy and safety have been demonstrated for short- and long-term use (24 weeks).​[145][156]​​ Thiopurine methyltransferase (TPMT) activity should be assessed before initiating therapy; dose should be reduced in patients with reduced TPMT activity. TPMT testing should also be considered in patients with abnormal complete blood counts that persist despite dose reduction of azathioprine. Adverse effects include gastrointestinal disturbances and abnormalities in liver enzymes and blood counts (e.g., lymphocytopenia). Regular monitoring of laboratory tests is required.[81] Due to a potentially increased risk of skin cancer, it should not be combined with ultraviolet light therapy.[50] It is not licensed for the treatment of atopic dermatitis in children but has proven beneficial in several retrospective pediatric case series.[50] Its main disadvantage is that it reaches maximum treatment effect only after 3-4 months.[50]

Mycophenolate is used off-label in the treatment of both adult and pediatric patients with treatment-refractory moderate to severe atopic dermatitis.[50][81] Evidence supporting its use for atopic dermatitis is limited and mainly based upon small, observational studies. In case series, the efficacy and safety of mycophenolate in children have been investigated; the drug has shown a positive treatment response with minimal adverse effects and appears to be better tolerated than azathioprine.[50][159]​ Adverse effects include headaches, gastrointestinal complaints, fatigue, and infections. Hematologic adverse effects include anemia, leukopenia, neutropenia, and thrombocytopenia, albeit rarely.[50] Prolonged treatment (≥1 year) is associated with increased risk of herpes infections.[158]​ Regular monitoring of laboratory tests is required.[50][81]

Primary options

dupilumab: children ≥6 months to 5 years of age and body weight 5-14 kg: 200 mg subcutaneously every 4 weeks; children ≥6 months to 5 years of age and body weight 15-29 kg: 300 mg subcutaneously every 4 weeks; children ≥6 years of age and body weight 15-29 kg: 600 mg subcutaneously initially, followed by 300 mg every 4 weeks; children ≥6 years of age and body weight 30-59 kg: 400 mg subcutaneously initially, followed by 200 mg every 2 weeks; children ≥6 years of age and body weight ≥60 kg and adults: 600 mg subcutaneously initially, followed by 300 mg every 2 weeks

OR

tralokinumab: children ≥12-17 years of age: 300 mg subcutaneously initially, followed by 150 mg every 2 weeks; adults: 600 mg subcutaneously initially, followed by 300 mg every 2 weeks (may consider 300 mg every 4 weeks after 16 weeks if body weight <100 kg)

Secondary options

upadacitinib: children ≥12 years of age and body weight ≥40 kg and adults <65 years of age: 15-30 mg orally once daily; adults ≥65 years of age: 15 mg orally once daily

OR

abrocitinib: children ≥12 years of age and body weight ≥25 kg and adults: 100-200 mg orally once daily

OR

baricitinib: children and adults: consult specialist for guidance on dose

Tertiary options

cyclosporine modified: children: consult specialist for guidance on dose; adults: 3-5 mg/kg/day orally given in 2 divided doses initially, adjust dose according to response

OR

methotrexate: children: consult specialist for guidance on dose; adults: 7.5 to 25 mg orally/subcutaneously once weekly on the same day of each week

OR

azathioprine: children and adults: consult specialist for guidance on dose

OR

mycophenolate mofetil: children and adults: consult specialist for guidance on dose

Plus – emollient

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Plus – 

emollient

Treatment recommended for ALL patients in selected patient group

Emollients rehydrate and improve the barrier function of the skin, and are an essential component of the daily skincare regimen for all patients.[80][85]​​​​​ [ Cochrane Clinical Answers logo ] ​​​ Emollients alone may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​ 

Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.

By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).[50]​​​

There is insufficient evidence to determine whether one emollient is better than another.[80][85]​​​​ However, increased lipid content is associated with improved hydration of the skin. Petrolatum effectively prevents water loss and may reduce T-cell-associated inflammation in atopic skin.[86]  

In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85][87] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[85]​​

American Academy of Dermatology guidelines make a conditional recommendation for the use of wet wrap therapy in adults with moderate to severe atopic dermatitis experiencing a flare, caveating that most data are from pediatric populations. They note that wet wrap therapy requires increased time and effort, as well as patient education, so the benefit in mild disease relative to the effort required is questionable.[85]

UK guidelines recommend that occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]​ Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days). Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled. The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]

Consider – topical corticosteroid

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ONGOING
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chronic or relapsing disease
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroids reduce inflammation and pruritus. Intermittent use on affected areas may be sufficient to control symptoms.

Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[85]​ Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[88]​ If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.

While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat flares.[89]

The potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45][85]​​ Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); can be effective in short courses for controlling flares of severe atopic dermatitis in adults but should not be used for children without specialist advice.

A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected.[45] Once the flare has settled, treating problem areas with topical corticosteroids twice weekly to prevent further flares could be considered for patients who experience frequent flares (e.g., 2 or 3 per month).[45][85][89]​​ Available data indicate fewer relapses and increased time between relapses with this strategy.[85]

Parents and caregivers may express concern regarding the use of topical corticosteroids and be reluctant to use these agents on their child's skin.[90][91]​ Ensuring that caregivers are aware of the mechanism of action of the corticosteroid, its efficacy and safety, and how to reduce the dose may contribute to improved treatment.[92]​ Patients can be informed that the FDA has approved several formulations of topical corticosteroid for infants ≥3 months of age who have atopic dermatitis.

The incidence of adverse events with topical corticosteroids is low.[85] Using the lowest-potency formulation that effectively treats a patient's dermatitis will help to minimize these. Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible. Hydrocortisone butyrate lotion has been shown to be safe and effective in children ages over 3 months.[93]

Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85] The related concepts of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) are less clearly characterized in the literature, with low strength of evidence reported in systematic reviews.[94][95]

Systemic adverse effects associated with topical corticosteroid use are rare, but may include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[85][96]​ These events usually occur in patients using large amounts of potent corticosteroids continuously for prolonged periods.[85] An association with cataracts or glaucoma is unclear, but minimizing periocular corticosteroid use is advised.[85]

Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[97]

Options include:[98] 

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, halobetasol, diflorasone.

Topical corticosteroid formulations included here are examples only. Formulations may vary and you should consult your local drug formulary for more information on available formulations and doses.

Primary options

hydrocortisone butyrate topical: (0.1%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily for up to 4 weeks

OR

fluticasone propionate topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

triamcinolone topical: (0.05% to 0.1%) children and adults: apply sparingly to the affected area(s) twice to four times daily

OR

fluocinolone topical: (0.025%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice to four times daily

OR

mometasone topical: (0.1%) children ≥2 years of age and adults: apply sparingly to the affected area(s) once daily

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

desoximetasone topical: (0.05 to 0.25%) children ≥10 years of age and adults: apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

halobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) once or twice daily for up to 2 weeks, maximum 50 g/week

OR

diflorasone topical: (0.05%) adults: apply sparingly to the affected area(s) twice to four times daily

Consider – topical calcineurin inhibitor

Back
ONGOING
|
chronic or relapsing disease
Consider – 

topical calcineurin inhibitor

Treatment recommended for SOME patients in selected patient group

Topical calcineurin inhibitors (e.g., pimecrolimus, tacrolimus) can be used as an alternative to, or in combination with, topical corticosteroids for acute flares. They are particularly useful for facial atopic dermatitis with eyelid involvement.[85]​ Topical calcineurin inhibitors should be used by physicians who are experienced in treating atopic dermatitis.

In one meta-analysis, calcineurin inhibitors were found to be the most effective topical agent in lessening pruritus associated with atopic dermatitis.[99] Another systematic review of 20 trials reported that tacrolimus (0.1%) was more effective than pimecrolimus, tacrolimus (0.03%), and low-potency corticosteroids for the treatment of atopic dermatitis.[100] In addition, tacrolimus (0.03%) was found to be superior to mild corticosteroids and pimecrolimus.[100] [ Cochrane Clinical Answers logo ] ​​

The most common adverse reactions seen with the use of calcineurin inhibitors are erythema, pruritus and skin irritation, or skin burning at the site of application.[50]

There is a theoretical risk of malignancy in patients using topical calcineurin inhibitors. The Food and Drug Administration recognizes that a causal relationship has not been confirmed, while advising that the long-term safety of these drugs has not been established, and recommending limiting their use to affected areas and avoiding long-term use when possible.

A prospective evaluation of the long-term safety of topical calcineurin inhibitors in approximately 8000 pediatric patients with atopic dermatitis (44,629 person-years) reported six confirmed incident cancers.[101] The cancer incidence was as expected, given matched background data (standardized incidence ratio 1.01, 95% CI 0.37 to 2.20); no lymphomas were reported. The study concluded that pediatric patients using a calcineurin inhibitor for atopic dermatitis are not at increased risk of developing malignancies.[101] Conversely, a subsequent systematic review to evaluate the risk of lymphoma associated with topical calcineurin inhibitor treatment concluded that the use of either topical tacrolimus or topical pimecrolimus significantly increased the risk of lymphoma.[102] Subgroup analyses showed that both topical tacrolimus and topical pimecrolimus significantly increased risk of non-Hodgkin lymphoma, but found no increased risk of Hodgkin lymphoma.[102] 

Primary options

pimecrolimus topical: (1%) children ≥2 years of age and adults: apply to the affected area(s) twice daily

OR

tacrolimus topical: (0.03%) children ≥2 years of age and adults: apply to the affected area(s) twice daily; (0.1%) adults: apply to the affected area(s) twice daily

Consider – topical crisaborole

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ONGOING
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chronic or relapsing disease
Consider – 

topical crisaborole

Treatment recommended for SOME patients in selected patient group

Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, is approved in the US for flares of mild to moderate atopic dermatitis in patients ages 3 months and older.[85]​ It does not have marketing authorization in the UK or Europe. Crisaborole improves disease severity and pruritus.[103][104][105]​​​

Adverse effects include application-site reactions (pain, burning, pruritus, stinging, and erythema); treatment-related adverse reactions are typically mild to moderate.[104]

Crisaborole is typically used twice daily; however, one randomized controlled trial found that long-term maintenance treatment with once-daily application resulted in delayed onset of first flare, greater number of flare-free days, and decreased number of flares compared to ointment with no drug in patients who had previously responded to twice-daily application, suggesting that once-daily treatment could be a potential long-term maintenance treatment option.[106]

Primary options

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily; consider reducing to once daily after clinical effect achieved

2nd line – phototherapy

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chronic or relapsing disease
2nd line – 

phototherapy

Ultraviolet (UV) phototherapy is frequently used in the management of moderate to severe generalized atopic dermatitis. It exerts beneficial effects through immunosuppressive, immunomodulating, and anti‐inflammatory actions.

Several forms of phototherapy are available for disease and symptom control, but comparative studies are limited, with low-certainty conclusions.[114]​ With respect to efficacy, the American Academy of Dermatology (AAD) does not differentiate between the different types of phototherapy; choice is informed by factors including availability, patient skin type, and patient use of photosensitizing medications.[81]​ Narrow-band UVB is the most widely used form of phototherapy in the US.[81] AAD guidelines do not recommend psoralen plus UVA (PUVA) due to insufficient evidence.[81]

Patients are treated two to three times weekly until clearance is achieved, at which point spacing between treatments is progressively increased, and treatment is often stopped altogether. Most regimens require treatments for 10-14 weeks; this requires a substantial time commitment for patients and may not be feasible depending on the distance required to travel, as well as school, work or other responsibilities.[81]

Management of hand atopic dermatitis will include consideration of patch testing, optimization of topical therapy, and possibly the need for phototherapy. If hand atopic dermatitis does not improve with phototherapy, a systemic drug such as alitretinoin may be added.[115]

Phototherapy is rarely used in children. European guidelines advise that it can be used after assessment of skin type, but that frequent and/or protracted treatment cycles should be avoided in children.[50]​ In the UK, guidelines recommend that phototherapy should only be considered for children with severe atopic dermatitis when other management options have failed, or are inappropriate.[45]

A small proportion of patients will experience a flare in atopic dermatitis with both sunlight and phototherapy. Common phototherapy adverse effects include: actinic damage, local erythema and tenderness, pruritus, burning, and stinging.[81]​ Phototherapy should not be used in patients with a history of skin cancer or with an increased risk of skin cancer (including photodamaged skin and those on systemic immunosuppressants).[50] Topical calcineurin inhibitors should not be used concomitantly with phototherapy.[116]

Plus – emollient

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chronic or relapsing disease
Plus – 

emollient

Treatment recommended for ALL patients in selected patient group

Emollients rehydrate and improve the barrier function of the skin, and are an essential component of the daily skincare regimen for all patients.[80][85]​​​​​ [ Cochrane Clinical Answers logo ] ​​​ Emollients alone may be sufficient to manage symptoms in a few patients. In all other patients, they are used in combination with other treatments. Emollients should be used in large amounts and more often than other treatments, both when atopic dermatitis is clear and while using all other treatments.[45]​ Regular use of emollient therapy has a demonstrated corticosteroid-sparing effect.[50]​​ 

Emollients may contain a humectant (e.g., glycol or urea) that promotes hydration of the stratum corneum and an occlusive agent (e.g., petrolatum) that reduces evaporation. Newer emollients may contain lipids at levels that mimic endogenous composition, or ceramides or filaggrin breakdown products.

By decreasing the dryness and improving the barrier function of the skin, emollients can improve symptoms of itch and pain, in addition to decreasing exposure to bacteria and sensitizing antigens. Individual preference determines choice; the selected emollient should not contain additives or sensitizing agents (e.g., fragrances or perfumes).[50]​​​

There is insufficient evidence to determine whether one emollient is better than another.[80][85]​​​​ However, increased lipid content is associated with improved hydration of the skin. Petrolatum effectively prevents water loss and may reduce T-cell-associated inflammation in atopic skin.[86]  

In children and adults with moderate to severe atopic dermatitis, the addition of wet wrap therapy to the topical regimen can result in faster resolution of symptoms.[85][87] Wet wrap therapy may help by occluding the topical agent for increased penetration, reducing water loss, and acting as a physical barrier against scratching.[85]​​

American Academy of Dermatology guidelines make a conditional recommendation for the use of wet wrap therapy in adults with moderate to severe atopic dermatitis experiencing a flare, caveating that most data are from pediatric populations. They note that wet wrap therapy requires increased time and effort, as well as patient education, so the benefit in mild disease relative to the effort required is questionable.[85]

UK guidelines recommend that occlusive dressings (including wet wrap therapy) can be used for localized or whole-body treatment of chronic lichenified atopic dermatitis in children in addition to emollients, or emollients and topical corticosteroids.[45]​ Localized dressings with emollients and corticosteroids should only be used for the short term (7-14 days). Whole-body dressing should only be initiated by a specialist, using topical corticosteroids for 7-14 days, but can be continued with emollients alone until the symptoms are controlled. The use of a wet wrap therapy in addition to calcineurin inhibitors should only be undertaken with specialist advice.[45]

Consider – topical corticosteroid

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chronic or relapsing disease
Consider – 

topical corticosteroid

Treatment recommended for SOME patients in selected patient group

Corticosteroids reduce inflammation and pruritus. Intermittent use on affected areas may be sufficient to control symptoms.

Patients are started on low- to medium-potency topical corticosteroids and may only require intermittent use on affected areas.[85]​ Patients who do not respond may require a higher-potency corticosteroid preparation during flares and continuous use of milder forms for maintenance therapy.[88]​ If symptoms are not controlled, a higher-potency corticosteroid preparation may have to be used for maintenance therapy.

While some guidelines recommend once-daily dosing of topical corticosteroids, many of the medications are approved for twice-daily (or more frequent) dosing by the Food and Drug Administration (FDA), depending on the corticosteroid. Similar efficacy has been reported for once-daily and twice-daily (or more frequent) use of potent topical corticosteroids to treat flares.[89]

The potency of the preparation should be tailored to the severity of atopic dermatitis, and may vary according to body site.[45][85]​ Mild potency for mild atopic dermatitis; moderate potency for moderate atopic dermatitis; potent for severe atopic dermatitis; face and neck, use mild potency, except for short-term (3-5 days) use of moderate potency for severe flares; flares in vulnerable sites (e.g., axillae and groin), moderate or potent preparations for short periods only (7-14 days); very high-potency topical corticosteroids can be effective in short courses for controlling flares of severe atopic dermatitis in adults but should not be used for children without specialist advice.

A different topical corticosteroid of the same potency should be considered as an alternative to stepping up treatment if tachyphylaxis is suspected.[45] Once the flare has settled, treating problem areas with topical corticosteroids twice weekly to prevent further flares could be considered for patients who experience frequent flares (e.g., 2 or 3 per month).[45][85][89]​​ Available data indicate fewer relapses and increased time between relapses with this strategy.[85]

Parents and caregivers may express concern regarding the use of topical corticosteroids and be reluctant to use these agents on their child's skin.[90][91]​ Ensuring that caregivers are aware of the mechanism of action of the corticosteroid, its efficacy and safety, and how to reduce the dose may contribute to improved treatment.[92]​ Patients can be informed that the FDA has approved several formulations of topical corticosteroid for infants ≥3 months of age who have atopic dermatitis.

The incidence of adverse events with topical corticosteroids is low.[85] Using the lowest-potency formulation that effectively treats a patient's dermatitis will help to minimize these. Children are at increased risk of systemic adverse effects because of their increased body surface area to weight ratio, and lower-potency formulations should be used whenever possible. Hydrocortisone butyrate lotion has been shown to be safe and effective in children ages over 3 months.[93]

Adverse effects of topical corticosteroids include skin atrophy, hypopigmentation, striae, purpura, focal hypertrichosis, acneiform eruptions, and telangiectasias.[85] Skin atrophy is generally the most concerning for physicians and patients. Risk factors for atrophy include higher-potency topical corticosteroid use, occlusion, use on thinner and intertriginous skin, older patient age, and long-term continuous use. Allergic contact dermatitis to topical corticosteroids or other ingredients in their formulations can be determined via patch testing.[85] The related concepts of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) are less clearly characterized in the literature, with low strength of evidence reported in systematic reviews.[94][95]

Systemic adverse effects associated with topical corticosteroid use are rare, but may include hypothalamic-pituitary-adrenal axis suppression, reduction of linear growth rate, Cushing syndrome, and reduction of bone density.[85][96]​ These events usually occur in patients using large amounts of potent corticosteroids continuously for prolonged periods.[85] An association with cataracts or glaucoma is unclear, but minimizing periocular corticosteroid use is advised.[85]

Percentages included in the name of the corticosteroid do not always correlate with its strength, so it is important to understand the potency of the corticosteroid before prescribing.[97]

Options include:[98] 

Low-potency: hydrocortisone, desonide

Mid-potency: fluticasone, triamcinolone, fluocinolone

High-potency: mometasone, betamethasone, desoximetasone

Very high-potency: clobetasol, halobetasol, diflorasone.

Topical corticosteroid formulations included here are examples only. Formulations may vary and you should consult your local drug formulary for more information on available formulations and doses.

Primary options

hydrocortisone butyrate topical: (0.1%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily

OR

desonide topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice daily for up to 4 weeks

OR

fluticasone propionate topical: (0.05%) children ≥3 months of age and adults: apply sparingly to the affected area(s) once daily for up to 4 weeks

OR

triamcinolone topical: (0.05% to 0.1%) children and adults: apply sparingly to the affected area(s) twice to four times daily

OR

fluocinolone topical: (0.025%) children ≥3 months of age and adults: apply sparingly to the affected area(s) twice to four times daily

OR

mometasone topical: (0.1%) children ≥2 years of age and adults: apply sparingly to the affected area(s) once daily

OR

betamethasone dipropionate topical: (0.05%) children ≥13 years of age and adults: apply sparingly to the affected area(s) once or twice daily

OR

desoximetasone topical: (0.05 to 0.25%) children ≥10 years of age and adults: apply sparingly to the affected area(s) twice daily

OR

clobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) twice daily for up to 2 weeks, maximum 50 g/week

OR

halobetasol topical: (0.05%) children ≥12 years of age and adults: apply sparingly to the affected area(s) once or twice daily for up to 2 weeks, maximum 50 g/week

OR

diflorasone topical: (0.05%) adults: apply sparingly to the affected area(s) twice to four times daily

Consider – topical crisaborole

Back
ONGOING
|
chronic or relapsing disease
Consider – 

topical crisaborole

Treatment recommended for SOME patients in selected patient group

Crisaborole, a nonsteroidal topical anti-inflammatory phosphodiesterase-4 inhibitor, is approved in the US for flares or maintenance treatment of mild to moderate atopic dermatitis in patients ages 3 months and older.[85]​ It does not have marketing authorization in the UK or Europe. Crisaborole improves disease severity and pruritus.[103][104][105]​​​​

Adverse effects include application-site reactions (pain, burning, pruritus, stinging, and erythema); treatment-related adverse reactions are typically mild to moderate.[104]

Crisaborole is typically used twice daily; however, one randomized controlled trial found that long-term maintenance treatment with once-daily application resulted in delayed onset of first flare, greater number of flare-free days, and decreased number of flares compared to ointment with no drug in patients who had previously responded to twice-daily application, suggesting that once-daily treatment could be a potential long-term maintenance treatment option.[106]

Primary options

crisaborole topical: (2%) children ≥3 months of age and adults: apply to the affected area(s) twice daily; consider reducing to once daily after clinical effect achieved

Consider – topical ruxolitinib

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ONGOING
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chronic or relapsing disease
Consider – 

topical ruxolitinib

Treatment recommended for SOME patients in selected patient group

Topical Janus kinase (JAK) inhibitors have the potential to reduce inflammation and improve pruritus, without the skin thinning associated with topical corticosteroid use.[107][108][109][110]

Topical ruxolitinib is approved in the US for the short-term and noncontinuous chronic treatment of mild to moderate atopic dermatitis in immunocompetent patients older than 12 years whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable.[111]​ Topical ruxolitinib is not currently approved for this indication in Europe.[50]

US guidelines differ in their recommendations regarding ruxolitinib. the American Academy of Dermatology guidelines include it in their treatment algorithm, whereas the American College of Allergy, Asthma and Immunology guidelines do not recommend it, citing concerns about the potential for serious adverse effects due to systemic absorption.[75][85][111]​​​​ The body surface area limitation for topical ruxolitinib is up to 20% due to these safety concerns.[85][112]

Primary options

ruxolitinib topical: (1.5%) children ≥12 years of age and adults: apply to the affected area(s) twice daily, maximum 60 g/week or 100 g/2 weeks; treatment area should not exceed 20% body surface area

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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