Atopic Dermatitis

Our Approach in Managing Atopic Dermatitis

Shree Hospitals — Life-saving care

Atopic dermatitis management requires patience — from both the clinician and the patient. It is a condition managed in layers: baseline emollient therapy that never stops, topical anti-inflammatory agents for flares, and escalating systemic or biologic therapy for those whose disease breaks through. Our eczema specialist dermatologist team in Mumbai, India establishes this layered approach at the first visit and adjusts it based on objective severity scoring not subjective impression.

1. Diagnosis & Severity AssessmentAtopic dermatitis is a clinical diagnosis no blood test confirms it.
   • Hanifin and Rajka criteria  major features: pruritus, typical morphology and distribution, chronic relapsing course, personal or family history of atopy (asthma, allergic rhinitis, food allergy)
   • SCORAD (SCORing Atopic Dermatitis)  combines extent, intensity, and subjective symptoms; mild <25, moderate 25–50, severe >50
   • IGA (Investigator's Global Assessment)  simple 5-point scale for clinical practice and treatment response monitoring
   • POEM (Patient-Oriented Eczema Measure) — patient-reported weekly symptom frequency; particularly useful for tracking real-world disease impact
   • Baseline investigations: total IgE, specific IgE or skin prick testing where food or environmental allergy is clinically suspected

2. Emollient Therapy — The Non-Negotiable FoundationSkin barrier dysfunction is the primary defect in atopic dermatitis. Emollients are not optional add-ons  they are core therapy.

• Apply within 3 minutes of bathing  the "soak and seal" technique; maximises moisture retention
• Quantity matters: adults with moderate-severe AD require 500g of emollient per week
• Emollient selection: ointments (most occlusive, best for dry thick skin), creams (lighter, for daytime), lotions (poor barrier function  generally not recommended in AD)
• Avoid fragrance, lanolin, and preservatives in emollient products  common contact sensitisers in AD patients
• Emollient use twice daily at minimum  not just during flares

3. Topical Anti-Inflammatory Therapy

• Topical corticosteroids (TCS) — first-line for flares; potency matched to site (mild for face/flexures, moderate-strong for body); fingertip unit guidance for quantity
• Proactive therapy  twice-weekly TCS application to previously affected sites even when clear  reduces flare frequency significantly; the most underused strategy in AD management
• Topical calcineurin inhibitors (TCIs)  Tacrolimus 0.1% (adults), 0.03% (children); Pimecrolimus  for face, eyelids, and intertriginous sites; no atrophy risk; steroid-sparing
• Topical PDE4 inhibitor (Crisaborole)  for mild-moderate AD; non-steroidal; safe for face and sensitive sites
• Topical JAK inhibitor (Ruxolitinib cream) emerging; rapid itch relief; approved for mild-moderate AD in adults; significant itch reduction within 12 hours

4. Systemic Therapy for Moderate to Severe AD
   When topical therapy fails to control moderate to severe disease:

• Cyclosporine  rapid onset; first-line systemic for severe AD; BP and renal monitoring; limited to 1–2 years
• Methotrexate : weekly dosing; slower onset than Cyclosporine; suitable for long-term use; teratogenic counselling
• Azathioprine  alternative systemic; TPMT enzyme testing before initiation to assess myelosuppression risk
• Short-course oral Prednisolone  for acute severe flares only; not for long-term control; rebound flare on stopping is common and predictable

5.Dupilumab & Biologic Therapy

Dupilumab for eczema represents the most significant advance in AD treatment in two decades.

• Dupilumab  anti-IL-4Rα monoclonal antibody; blocks IL-4 and IL-13 signalling — the dominant type 2 inflammatory drivers in AD
• Every-2-week subcutaneous injection; approved from 6 months of age
• Response rates: IGA 0/1 (clear or almost clear skin) in 38–44% at week 16; EASI-75 in 51–59%
• Significantly reduces itch scratch cycle intensity  itch reduction often begins within the first week
• Common side effect: conjunctivitis  managed with artificial tears and ophthalmology review if persistent
• Tralokinumab  anti-IL-13; alternative biologic; similar efficacy; monthly dosing after induction
• JAK inhibitors (Abrocitinib, Upadacitinib, Baricitinib)  oral daily therapy; faster onset than Dupilumab; highly effective for refractory moderate-severe AD; require screening for TB, hepatitis B, and lipids before initiation 

  6.Trigger Identification & Environmental Control

• House dust mite ;the most important environmental trigger; mattress and pillow encasements, weekly hot washing of bedding, HEPA vacuum
• Sweat and heat;  exacerbate the itch scratch cycle; cotton loose clothing, cool sleeping environment
• Food triggers  significant in children under 5 with severe AD; structured elimination and reintroduction under dietetic supervision; not appropriate as first-line management without confirmed sensitisation
• Contact allergens ; fragrance, nickel, preservatives; patch testing where contact dermatitis is superimposed
• Skin infections : Staphylococcus aureus colonises AD skin and drives inflammation; antiseptic bath additives, bleach baths (dilute sodium hypochlorite 0.005%) reduce bacterial load