Step-Wise Treatment of Atopic Dermatitis: Basics and Beyond

Noreen Heer Nicol, PhD, RN, FNP, NEA-BC


Pediatr Nurs. 2020;46(2):92-98. 

In This Article

Abstract and Introduction


Atopic dermatitis (AD) is a global public health problem and one of the most common chronic, relapsing inflammatory skin diseases. Successful AD management strategies are implemented in a stepwise approach tailored to the individual patient and are severity-based. This review highlights bathing and daily use of moisturizers as the cornerstone of AD management. This foundational skin care is required for every patient with AD, regardless of additional therapy. Patients are often unclear about the specific instructions to complete this skin care. Every pediatric care provider plays an important role in ensuring good foundational skin care incorporating bathing and daily moisturizer use for all patients with AD.


A topic dermatitis (AD) is the most common form of eczema and remains a complex, common, chronic, and relapsing inflammatory skin disorder of infants, children, and adolescents, but can affect patients of any age. Prevalence has increased to up to 18% in school-aged children and approximately 7% of adults in the United States and other industrialized countries, and has become a global public health problem (Odhiambo et al., 2009; Silverberg & Hanifin, 2013). Atopic comorbidities of asthma, allergic rhinitis, and food allergies are well recognized in patients with AD (Kapoor et al., 2008; Nicol, 2005a; Schneider et al., 2016).

Atopic dermatitis occurs in genetically predisposed individuals with a defective skin barrier and abnormal immune responses to irritants, allergens, and microbial organisms (Boguniewicz & Leung, 2011). AD is characterized by abnormal skin barrier function associated with abnormalities in cornified envelope genes, reduced ceramide levels, increased levels of endogenous proteolytic enzymes, and enhanced transepidermal water loss (Cork et al., 2006). Skin barrier may also be damaged by exposure to exogenous proteases from Staphylococcus (S.) aureus. This compromised skin barrier increases moisture loss and creates dry, easily irritated, pruritic, and hypersensitive skin. In this compromised state, the skin is more prone to infections with bacteria, fungi, or viruses, and inflammation due to irritants and allergens. This problem can become aggravated during the dry winter months and in certain work and daily environments.

An important consideration is that even skin that is not flaring is still compromised in the patient with AD. Evidence suggests that non-lesional skin can share immunological features (Brunner et al., 2017; Unger et al., 2017), microbiome alterations (Lloyd-Lavery et al., 2019), and biomarker changes (Unger et al., 2017) seen in lesional skin. One primary goal of AD therapy should be to repair the skin barrier, thereby reducing the risk of flares.

Patients with AD have severe pruritus, and their disease disrupts sleep and negatively impacts the quality of life of patients and families (Chamlin, 2006; Silverberg et al., 2019). When AD remains in poor control, patients and caregivers experience multiple medical and psychosocial problems. AD can have a notable impact on quality of life, with studies reporting that AD is associated with lower overall health and frequent avoidance of social interactions and activities (Chiesa Fuxench et al., 2019), as well as significantly increased rates of anxiety and depression (Silverberg et al., 2019).