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

National and International AD Treatment Guidelines

National and international guidelines address AD care in a stepwise fashion and emphasize foundational skin care of AD at every level of severity as the cornerstone of AD management. This review references AD guidelines or AD management reviews that are international, including publications from the United States, Canada, the United Kingdom, Europe, Asia, the Asia-Pacific region, Australia, and Africa (Adkis et al., 2006; Boguniewicz et al., 2018; Eichenfield et al., 2014; Eichenfield et al., 2015; Eichenfield et al., 2017; Le Poidevin et at., 2019; Ring et al., 2012; Schneider et al., 2012; Wollenberger et al., 2018). As new AD therapies continue to emerge, including biologics, treatment options for moderate-to-severe atopic dermatitis improve dramatically. Proper utilization management of these new therapies requires that they are reserved for appropriate patients who fail conventional management, including this foundational skin care. All pediatric care practitioners play an important role in ensuring good basic skin care principles for all patients with AD.

Treatment based on severity of AD is completed in the stepwise manner as described in the PRACTALL Consensus (Adkis et al., 2006) or the Practice Parameter treatment algorithm (Boguniewicz et al., 2018). Figure 1 is a simplified combination of these models. The figure outlines care across the entire spectrum of disease from "normal appearing AD skin" or dry skin to mild-to-moderate to severe AD.

Figure 1.

Stepwise Management of Atopic Dermatitis
Notes: TCI = topical calcineurin inhibitor, TCS = topicalcorticosteroid, PDE4 = phosphodiesterase 4 inhibitor, WWT = wet wrap therapy.
Sources: Adapted from Akdis et al., 2006; Boguniewicz et al., 2018.

Successful strategies for managing the spectrum of AD require a systematic, multipronged approach. This approach emphasizes patient education; identifying and eliminating flare factors, such as irritants, allergens, and emotional stressors; and incorporating skin hydration, pharmacologic, and non-pharmacologic therapies (Boguniewicz & Nicol, 2002; Nicol & Boguniewicz, 2008). Management is aimed at preventing dry skin, treating the rash, and improving the itch. Treatment plans are individualized to address each patient's skin disease reaction pattern, including the acuity of the rash (Brar et al., 2019). Regardless of etiology, skin with compromised barrier integrity can both cause and exacerbate AD factors. The objective of this review is to provide the evidentiary basis for and clarify the role of foundational skin care for every patient with AD, incorporating hydration and moisturizer use that every pediatric health care provider could recommend.