Moisturizers are essential in the baseline treatment for all severities of patients with AD. They should be applied at least 2-3 times a day, with more severely affected patients requiring more frequent application. Moisturizers should be applied even when the AD is quiescent, and they are recommended to be applied to the whole body.
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At least 2-3 times a day. It is best applied within 3-5 minutes after a bath or shower. However, it can be used even without a bath or shower.
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Humectants (urea and lactic acid) may cause subjective irritation and irritant dermatitis. Fragrances, preservatives, and additives in emollients may cause allergic or photoallergic contact dermatitis and contact urticaria. Occlusives (mineral oil), acneiform eruptions, and contact dermatitis (lanolin) may cause folliculitis.
- There has yet to be a consensus on whether moisturisers should be applied before or after the application of topical corticosteroids or calcineurin inhibitors.
- Oil-based ointments (e.g., soft white paraffin) are preferred to water-based creams when the skin is very dry or when there are acute flares with broken skin.
- Epicutaneous sensitisation to certain foods can occur by applying moisturisers that contain food extracts, e.g. colloidal oatmeal.
Wet wraps involve the use of a double layer of cotton bandages comprising of a wet inner layer and a dry outer layer, worn over emollients and/or diluted topical corticosteroid creams. It is used as a step-up treatment to quickly reduce the severity, itch, and pain of AD during acute flare-ups, especially in children with widespread, moderate to severe AD.
- Evaporation of water from the wet bandages helps to cool the skin, relieve inflammation, itch and discomfort.
- Skin rehydration through improved absorption of moisturisers.
- Enhanced absorption of topical corticosteroids into the superficial and deeper skin layers.
- Protection by acting as a barrier against direct scratching, allowing the skin to heal.
- Puberty is a relative contraindication due to the greater risk for development of striae.
- Wet wraps should be avoided if there are overt signs of secondary skin infections, e.g., impetigo or eczema herpeticum.
- Uncooperative child
- A bowl of lukewarm water
- Bath oil (optional)
- Low potency topical steroids (e.g. 0.025% betamethasone valerate or equivalent) or diluted topical corticosteroids at 10% dilutions of potent topical corticosteroids for the body and 5% dilutions for the face. Alternative anti-inflammatory treatment options are topical calcineurin inhibitors if available.
- Moisturisers
- Tubular bandages / body vest / leggings / cotton pajamas
- Wash your hands
- Measure the lengths of tubular bandages needed; two for each limb
- Fill the bowl with lukewarm water
- Add one capful of bath oil to the bowl (optional)
- Apply a thin layer of anti-inflammatory topicals over affected areas
- Apply a generous amount of moisturiser to the whole body and face
- The first layer of cotton garment/bandages is soaked in lukewarm water and put on the skin after gently wringing excess water
- Apply the second dry layer and optionally, the patient’s pajamas or clothes
- The first layer of cotton garment/bandage is re-wet every 2 to 3 hours by peeling back the second, dry layer and spraying lukewarm water with a sprayer. During the night, rewetting is stopped to ensure a restful sleep
Video link: https://www.youtube.com/watch?v=nQimo9nQNEA
Reported side effects are not common and usually temporary and mild. They include systemic absorption of topical corticosteroids, and increased risks of skin infections, such as impetigo and molluscum contagiosum.
Topical corticosteroids (TCS) have been the cornerstone of AD management. If used carefully and under supervision, TCS is a highly effective and safe anti-inflammatory agent. The strength and mode of application of the TCS depend on the severity of the dermatitis, the sites to be treated, and the patient's age.
- Active bacterial infection is a relative contraindication to using TCS (furuncles and carbuncles, cellulitis, erysipelas, lymphangitis, and erythrasma) * see key considerations.
- Active dermatophyte infection
- Signs of TCS related adverse effects – Striae, atrophy, telangiectasia, acneiform eruptions.
- Proven contact allergy to corticosteroids (other classes may be used)
- Different classes of TCS potencies are available (Table). Generally, class 5 or 6 TCS are preferred for the face and intertriginous areas and class 3 or 4 TCS for non-facial areas. Rescue medication with a class 2 TCS may be used occasionally, especially for severe disease flares.
- For active inflammation, twice-daily application of appropriate-strength TCSs for up to 2-4 weeks is commonly recommended; once-daily application might be sufficient for many patients. The frequency of applications can be reduced when eczema improves.
- For long-term maintenance therapy, application once or twice weekly to areas that commonly flare might be appropriate to stop relapse for some patients (proactive therapy).
- The concept of the fingertip unit (FTU; approximately 0.5 g of topical agent - the amount from the distal interphalangeal joint to the fingertip), are recommended, a variety of recommendations exist.
- asdadad
- The duration of treatment should not be greater than 2-4 weeks, regardless of potency. High-potency steroids should not be administered for a longer than 2 weeks, and after this period, should be tapered to avoid adverse effects.
- The use of lower-potency steroids, morning-only applications, alternate-day or weekend only treatment should be preferred after acute exacerbations have been controlled and the extent of occlusion should be decreased.
- Local side effects include cutaneous atrophy (especially at intertriginous sites), striae, purpura and ecchymoses, hypertrichosis, hypopigmentation, delayed wound healing, rosacea, periorificial dermatitis and acneiform eruptions.
- Systemic side effects include glaucoma, cataracts, hypothalamic-pituitary suppression, Cushing syndrome, hypertension, and hyperglycemia.
- TCS should be used at the lowest effective dose to achieve disease control.
- Most patients and caregivers tend to underuse TCS, partly due to corticosteroid phobia.
- Patients and caregivers should be advised to apply TCS until the eczema area is not red, not itchy and not bumpy.
- If there is no improvement or worsening of lesions after 2-4 weeks of treatment, re-assessment of the diagnosis and compliance should be considered.
- Infants and young children with AD should be treated with less potent TCSs, because they have an increased risk of adrenal suppression from potent TCSs.
- If secondary bacterial infections - can add oral antibiotics, add topical antibiotics to topical corticosteroids, or combination topical antibiotics / corticosteroids
Topical calcineurin inhibitors (TCI), tacrolimus and pimecrolimus, are non-steroidal anti-inflammatory agents that have been integral in the treatment of AD. They are useful in AD refractory to TCS, requiring chronic TCS, or involving sensitive sites, such as the face and intertriginous areas.[7] Tacrolimus ointment and pimecrolimus cream are applied twice a day.
Due to the higher potency of tacrolimus (0.03%‐0.1%) compared to pimecrolimus, most guidelines recommend tacrolimus for moderate‐to‐severe disease and pimecrolimus cream (1%) for mild‐to‐moderate AD.
Hypersensitivity to the tacrolimus, pimecrolimus or its excipients
Tacrolimus is available in 2 potencies, with the 0.03% ointment recommended for mild to moderate eczema and the 0.1% ointment recommended for moderate to severe eczema. Pimecrolimus is available in 1% cream formulation and is recommended for mild to moderate eczema. TCI are recommended to be applied twice daily. Proactive treatment is recommended for recurrent AD, with application of TCI twice weekly to prevent flares.
None required. All guidelines state that there is currently no direct evidence to support the claim that TCI use increases risk for malignancy.[7,13]
Most common side effects include erythema, stinging or burning, and irritation at application site. These side effects are more common on more severely affected AD skin and improves with continued application. The side effects are more common with tacrolimus ointment compared to pimecrolimus cream.
In patients who do not tolerate tacrolimus because of burning or stinging, a lower strength formulation or pimecrolimus may be better tolerated. It is also recommended to use TCS on more irritated AD skin for a few days before switching to TCI if the burning or stinging is not tolerable. Other methods include cooling the tube of TCI in the refrigerator before application or using a fan to cool the skin after application. Generally, the stinging improves with improvement in eczema upon continued use of the TCI.
Crisaborole is a nonsteroidal boron-based molecule that selectively inhibits phosphodiesterase-4 (PDE4). Crisaborole ointment, 2%, is currently the only PDE4 inhibitor available for treatment of mild to moderate AD. It is approved for use for mild to moderate atopic dermatitis in infants and children ≥3 months of age.
Hypersensitivity to crisaborole or any component of the formulation e.g. EDTA or prophylene glycol.
Crisaborole is recommended to be applied twice daily to affected areas.
No routine monitoring is indicated.
Application site pain, burning or stinging has been reported in a proportion of patients.
Phototherapy is a second-line treatment modality for moderate to severe AD. Different phototherapy modalities are used to treat AD, including narrow-band UVB (NB-UVB), combination NB-UVB and UVA, and UVA1. Thinner lesions respond better to UVB, while thicker lesions (e.g., prurigo nodularis) respond better with addition, UVA, or UVA1 phototherapy. Response rates to phototherapy range between 60-75%.
Phototherapy exerts immunomodulatory, immunosuppressive, anti-inflammatory, and anti-pruritic effects on AD.
Phototherapy is relatively safe but must be avoided in patients with photosensitive dermatoses, including xeroderma pigmentosum and lupus erythematosus. Other contraindications include patients on systemic immunosuppressants, especially cyclosporine, as there is an increased risk of development of skin cancers, and patients on photosensitising medications.
Phototherapy is usually commenced at a frequency of 2-3 times per week. It should be performed at least 2 days apart. The response to phototherapy is slow and can require 2-3 months before a response is seen. Thereafter, the frequency of phototherapy can be reduced according to the clinical response.
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Short-term side effects include erythema and sunburn, increased itch and xerosis, and blister formation. Medium-term side effects include increased tan. Long-term side effects include skin ageing and increased risk of skin cancer.
Phototherapy is a second-line treatment modality for moderate to severe AD. Different phototherapy modalities are used to treat AD, including narrow-band UVB (NB-UVB), combination NB-UVB and UVA, and UVA1. Thinner lesions respond better to UVB, while thicker lesions (e.g., prurigo nodularis) respond better with addition, UVA, or UVA1 phototherapy. Response rates to phototherapy range between 60-75%.
Phototherapy exerts immunomodulatory, immunosuppressive, anti-inflammatory, and anti-pruritic effects on AD.
Phototherapy is relatively safe but must be avoided in patients with photosensitive dermatoses, including xeroderma pigmentosum and lupus erythematosus. Other contraindications include patients on systemic immunosuppressants, especially cyclosporine, as there is an increased risk of development of skin cancers, and patients on photosensitising medications.
Phototherapy is usually commenced at a frequency of 2-3 times per week. It should be performed at least 2 days apart. The response to phototherapy is slow and can require 2-3 months before a response is seen. Thereafter, the frequency of phototherapy can be reduced according to the clinical response.
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Short-term side effects include erythema and sunburn, increased itch and xerosis, and blister formation. Medium-term side effects include increased tan. Long-term side effects include skin ageing and increased risk of skin cancer.
Phototherapy is a second-line treatment modality for moderate to severe AD. Different phototherapy modalities are used to treat AD, including narrow-band UVB (NB-UVB), combination NB-UVB and UVA, and UVA1. Thinner lesions respond better to UVB, while thicker lesions (e.g., prurigo nodularis) respond better with addition, UVA, or UVA1 phototherapy. Response rates to phototherapy range between 60-75%.
Phototherapy exerts immunomodulatory, immunosuppressive, anti-inflammatory, and anti-pruritic effects on AD.
Phototherapy is relatively safe but must be avoided in patients with photosensitive dermatoses, including xeroderma pigmentosum and lupus erythematosus. Other contraindications include patients on systemic immunosuppressants, especially cyclosporine, as there is an increased risk of development of skin cancers, and patients on photosensitising medications.
Phototherapy is usually commenced at a frequency of 2-3 times per week. It should be performed at least 2 days apart. The response to phototherapy is slow and can require 2-3 months before a response is seen. Thereafter, the frequency of phototherapy can be reduced according to the clinical response.
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Short-term side effects include erythema and sunburn, increased itch and xerosis, and blister formation. Medium-term side effects include increased tan. Long-term side effects include skin ageing and increased risk of skin cancer.
Dupilumab is a fully human monoclonal antibody that inhibits the signaling of the interleukin-4 and interleu¬kin-13 pathways. It has been approved to treat patients aged 6 months and above with moderate-to-severe AD, whose disease is not adequately controlled with topical therapies or when systemic therapies are not advisable.
Dupilumab is a fully human monoclonal antibody that inhibits the signaling of the interleukin-4 and interleu¬kin-13 pathways. It has been approved to treat patients aged 6 months and above with moderate-to-severe AD, whose disease is not adequately controlled with topical therapies or when systemic therapies are not advisable.
Dupilumab is administered by subcutaneous injection. The dose is based on the age and weight of the patient.
18 years and above
- Loading dose of 600 mg (two 300 mg injections), followed by 300mg every other week (Q2W)
6 to 17 years
- 15 to less than 30 kg: Loading dose of 600mg (two 300mg injections)followed by 300mg every 4 weeks (Q4W)
- 30 to less than 60 kg: Loading dose of 400mg (two 200mg injections) followed by 200mg every other week (Q2W) or loading dose of 600 mg followed by 300 mg every 3 weeks (Q3W)
- 60kg or more: Loading dose of 600mg (two 300mg injections) followed by 300mg every other week (Q2W)
6 months to 5 years
- 5 to less than 15 kg: 200mg every 4 weeks (Q4W)
- 15 to less than 30 kg: 300mg every 4 weeks (Q4W)
No routine laboratory testing is required.
Most common side effects include nasopharyngitis, conjunctivitis, blepharitis, eye pruritus, dry eyes, oral herpes, headache, eosinophilia, exacerbation of AD and injection-site reactions.
Less common side effects that have been reported include hypersensitivity reactions such as anaphylaxis, serum sickness, urticarial and rash, arthralgia/arthritis, and paradoxical head and neck erythema.
Cyclosporin is commonly prescribed as a first-line treatment for moderate-to-severe AD, with suboptimal response to topical therapies. A higher dos¬age of 5 mg/kg/day yields a better response and is more efficacious than a lower dosage. Nonetheless, the lowest dose for control of disease is recommended to min¬imize side effects.
Absolute contraindications:
- Significantly reduced renal function
- Live attenuated vaccines
- Hypersensitivity to cyclosporin or any ingredients in formulation
- Uncontrolled or severe hypertension
- Serious infections
- Immune compromise
- Hypertension which cannot be controlled by 2 types of antihypertensive drugs within 4 months of treatment
- Hyperuricemia
Treatment can be initiated at a dose of 2.5 – 3.5 mg/kg/day and can be increase to maximum dose of 5 mg/kg/day. It is recommended not to exceed maximum dose of 300 mg/day. If adequate response is attained, the dose can be gradually tapered by 0.5-1 mg/kg/day every few weeks. Dose adjustments should be based on clinical response and side effects.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include complete blood count (CBC), renal function tests, and liver function test. Regular monitoring of blood pressure and renal function should be undertaken while on cyclosporin.
Most common side effects include hypertension, impaired renal function, and increase risk of serious infections. The risk increases with higher doses of cyclosporin.
Methotrexate is recommended as 2nd line treatment for children and adolescents with moderate-to-severe AD, with suboptimal response to topical therapies.
- Serious infections
- Severe kidney and liver dysfunction
- Bone marrow suppression
- Pregnancy and breastfeeding
- Pulmonary fibrosis or poor lung function
- Active peptic ulcer
The starting doses are 0.3-0.5 mg/kg/week, up to a maximum of 25 mg/week. The dose can be increased weekly in steps of 2.5-5 mg/week. Consider subcutaneous administration above 15 mg/week for better bioavailability.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function tests. Regular monitoring of CBC and liver function should be performed. Consider a fibroscan to monitor for liver fibrosis after cumulative dose of 2-3 grams of methotrexate.
Most common side effects include nausea, vomiting, mouth or lips ulcers, impaired hepatic and bone marrow function, and increased risk of serious infections.
Azathioprine is recommended as a second line treat¬ment for moderate-to-severe AD patients, poorly controlled with topical therapies, and are unre¬sponsive or develop adverse effects from cyclospo¬rin.
- Hypersensitivity to azathioprine or any ingredients in formulation
- Serious infections
- Severely impaired hepatic function
- Severely impaired bone marrow function
- Pancreatitis
- Live attenuated vaccines
- Known malignancy
- Pregnancy and breastfeeding
- Drug interaction to azathioprine: warfarin and allopurinol
The recommended dosage of azathioprine is 1-2.5 mg/kg/day in children and 1-3 mg/kg/day in older adolescents. Initial recommended starting dose is 1 mg/kg/day. Recommended maximum dose is 150 mg / day.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT should be performed. TPMT and NUDT genotyping or levels are performed in some countries before commencing on azathioprine.
Most common side effects include impaired hepatic and bone marrow function and increased risk of serious infections.
There are some reports on the efficacy of mycopheno¬late mofetil in patients with refractory AD who are unre¬sponsive or develop adverse effects to cyclosporin, azathioprine or methotrexate.
- Hypersensitivity to mycophenolate mofetil or any ingredients in formulation
- Severe infections
- Pregnancy (category D)
- Breastfeeding
- Live attenuated vaccines
The rec¬ommended dosages in children are 40-50 mg/kg/day divided twice daily, 30-40 mg/kg/day in adolescents and adults, up to a maximum dose of 2 g/day.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT.
Most common side effect is increased risk of serious infections. Live vaccines should be avoided.
The JAK inhibitors, abrocitinib (JAK1), baricitinib (JAK1/2), and upadacitinib (JAK1) have been approved for the treatment of moderate-to-severe AD, whose disease is not adequately controlled with topical therapies, other systemic therapies, including biologics, or when other therapies are not advisable. All 3 JAK inhibitors are currently approved for adults, but only abrocitinib and upadacitinib are approved for adolescents 12 years and above. None are currently approved for use in children < 12 years of age.
- Hypersensitivity to the active substance or to any of the excipients
- Active serious systemic infections, including tuberculosis (TB)
- Severe hepatic impairment
- Pregnancy and breast-feeding (see section 4.6).
- Upadacitinib:
- For adults and adolescent patients (12+ years) weighing at least 40 kg, initiate treatment with 15 mg orally once daily.
- If an adequate response is not achieved, consider increasing the dosage to 30 mg once daily
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT.
Most common side effect is increased risk of serious infections. Live vaccines should be avoided.
The JAK inhibitors, abrocitinib (JAK1), baricitinib (JAK1/2), and upadacitinib (JAK1) have been approved for the treatment of moderate-to-severe AD, whose disease is not adequately controlled with topical therapies, other systemic therapies, including biologics, or when other therapies are not advisable. All 3 JAK inhibitors are currently approved for adults, but only abrocitinib and upadacitinib are approved for adolescents 12 years and above. None are currently approved for use in children < 12 years of age.
- Hypersensitivity to the active substance or to any of the excipients
- Active serious systemic infections, including tuberculosis (TB)
- Severe hepatic impairment
- Pregnancy and breast-feeding (see section 4.6).
- Abrocitinib Doses
- 100 to 200 mg per day, with the 200 mg dose being recommended for patients who are not responding to the 100 mg dose.
- 50 mg dose should be used to treat patients with moderate renal impairment, patients receiving treatment with inhibitors of cytochrome P450, or patients who are known or suspected to be poor metabolizers of CYP2C19.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT.
Most common side effect is increased risk of serious infections. Live vaccines should be avoided.
The JAK inhibitors, abrocitinib (JAK1), baricitinib (JAK1/2), and upadacitinib (JAK1) have been approved for the treatment of moderate-to-severe AD, whose disease is not adequately controlled with topical therapies, other systemic therapies, including biologics, or when other therapies are not advisable. All 3 JAK inhibitors are currently approved for adults, but only abrocitinib and upadacitinib are approved for adolescents 12 years and above. None are currently approved for use in children < 12 years of age.
- Hypersensitivity to the active substance or to any of the excipients
- Active serious systemic infections, including tuberculosis (TB)
- Severe hepatic impairment
- Pregnancy and breast-feeding (see section 4.6).
- Baricitinib Doses
- Starting dose is 2 mg/d, increasing to 4 mg/d if disease activity is not controlled.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT.
Most common side effect is increased risk of serious infections. Live vaccines should be avoided.
The JAK inhibitors, abrocitinib (JAK1), baricitinib (JAK1/2), and upadacitinib (JAK1) have been approved for the treatment of moderate-to-severe AD, whose disease is not adequately controlled with topical therapies, other systemic therapies, including biologics, or when other therapies are not advisable. All 3 JAK inhibitors are currently approved for adults, but only abrocitinib and upadacitinib are approved for adolescents 12 years and above. None are currently approved for use in children < 12 years of age.
- Hypersensitivity to the active substance or to any of the excipients
- Active serious systemic infections, including tuberculosis (TB)
- Severe hepatic impairment
- Pregnancy and breast-feeding (see section 4.6).
- Baricitinib Doses
- Starting dose is 2 mg/d, increasing to 4 mg/d if disease activity is not controlled.
Infective screens should be performed in endemic areas (e.g., hepatitis B and C, HIV, tuberculosis). Baseline monitoring include CBC, renal function test, and liver function test. Regular monitoring of CBC and LFT.
Most common side effect is increased risk of serious infections. Live vaccines should be avoided.
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