Choosing the Right Topical Therapy for Patients With Atopic Dermatitis (AD): Balancing Risk and Efficacy
Topical Corticosteroids (TCS)
- First-line anti-inflammatory agents with established efficacy
- Potency selection based on: disease severity, body location, patient age, and treatment duration
- Higher potency reserved for acute flares; lower potency for maintenance and sensitive areas
- Monitor for local adverse effects: skin atrophy, telangiectasia, striae
- Systemic absorption concerns primarily with high-potency/extended use, especially in children
Topical Calcineurin Inhibitors (TCIs)
- Tacrolimus (0.03%, 0.1%) and pimecrolimus (1%) are steroid-sparing alternatives
- Particularly valuable for facial, genital, and intertriginous areas
- No risk of skin atrophy, making them suitable for long-term maintenance
- Initial application may cause transient burning/stinging
- Black box warning regarding theoretical malignancy risk, though not substantiated by long-term data
Phosphodiesterase-4 (PDE4) Inhibitors
- Crisaborole 2% ointment approved for mild-to-moderate AD
- Favorable safety profile with minimal systemic absorption
- Main side effect is application site discomfort
- Generally less potent than moderate-to-high potency TCS
- Consider for maintenance therapy or steroid-sensitive areas
Emerging Topical Options
- JAK inhibitors (e.g., ruxolitinib, delgocitinib) showing promising efficacy
- Antimicrobial peptides targeting the microbiome dysbiosis in AD
- Commensal-derived products to restore microbiome balance
Application Strategies
- Fingertip unit (FTU) guidance for appropriate quantity
- Proactive twice-weekly application to previously affected sites reduces relapse rates
- Consider occlusion techniques for recalcitrant areas (limited duration)
- Wet wrap therapy for severe flares in pediatric patients
Risk Mitigation Approaches
- Rotation strategies to minimize adverse effects
- Clear instructions for duration of use and quantity
- Regular monitoring for local/systemic adverse effects
- Consideration of "weekend therapy" maintenance regimens
Patient-Specific Considerations
- Infants/Children: Prioritize lower potency agents, careful monitoring for systemic effects
- Pregnancy/Lactation: Prefer medium/low-potency TCS, limited application areas
- Occupational AD: Consider practical application timing and vehicle selection
- Recalcitrant Disease: Combination approaches with different mechanisms of action
Treatment Adherence Optimization
- Selection of appropriate vehicle (ointments for dry lesions, creams for weeping lesions)
- Patient preference consideration (texture, scent, ease of application)
- Clear written instructions with visual aids
- Follow-up assessment of technique and response