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


Daily or twice-daily use of moisturizers is recommended in national and international AD guidelines as the cornerstone of basic disease management. A comprehensive review of 14 independent, published AD guidelines from around the globe revealed that daily moisturization was a consistent recommendation for the management of AD (LePoidevin et al., 2019). Moisturizers are a steroid-sparing standard of care and useful for both AD prevention and AD therapy (Fleischer et al., 2017). In mild AD, a daily moisturizer may be the primary therapy and should also be maintained for the treatment of moderate and severe disease (Eichenfield et al., 2014; Wollenberg, 2018).

Moisturizers selection criteria should be based on proven clinical effectiveness in improving the skin barrier and improving the symptoms of AD. Moisturizers may reduce severity of AD and signs of inflammation, including pruritus, erythema, fissuring, and lichenification. In a Cochrane Database Review of 77 studies of emollient and moisturizer use in eczema, moisturizer use resulted in lower objective severity scores, fewer flares with prolonged time to flare, and less topical corticosteroid use (van Zuuren et al., 2017). There was a lower investigator-assessed disease severity with regular moisturizer use that was further improved when combined with active topical treatment, such as those outlined in Steps 2 and 3 of Step-Care (see Figure 1) (van Zuuren et al., 2017).

Moisturizers are not created equal and are confusing to consumers with the plethora of products on the market. Formulations and vehicles are multiple, including ointments, creams, lotions, gels, oils, foams, and more. Traditionally, ointments and other occlusives are thought to be the most beneficial for eczema due to their protective effects, while creams were assumed to provide better moisturization than lotions due to their greater viscosity. However, all premises are no longer universally true as modern technology has allowed the development of efficacious, more aesthetically pleasing formulations (Draelos, 2013). Certain well-formulated and tested moisturizers in lotion and cream vehicles may be very effective with improved compliance and consequently outcomes.

Some components of topical moisturizers treat underlying xerosis and inflammation by maintaining skin hydration while reducing transepidermal water loss. Moisturizers have evolved from providing basic barrier protection (occlusives), to hydrating care (humectant-enriched), to the development of products that address specific skin conditions (therapeutic). Therapeutic moisturizers for AD are specifically formulated with ingredients that target symptoms of AD, such as itch, inflammation, or compromised skin barrier (Elias et al., 2019).

Emollients, such as glycol, glyceryl stearate, and soy sterols, lubricate and soften the skin, whereas occlusive agents, such as petrolatum and dimethicone, help the skin retain moisture by reducing TEWL to evaporation. Humectants, such as glycerol, glycerin, urea, and propylene glycol, help attract and retain water in the skin (Eichenfield et al., 2014). Colloidal oatmeal contains a mixture of various dermatologic active compounds that provide moisturizing, skin-protectant, anti-inflammatory, antioxidant, and antipruritic effects. The starches and -D-glucans in oatmeal help create an occlusive barrier that both moisturizes and relieves itch, while antioxidants, such as avenanthramides, vitamin E, and ferulic acid, have demonstrated anti-inflammatory activity (Fowler et al., 2012). Other possible important adjuvants include menthoxypropanediol, which is associated with a cooling sensation, and licochalcone A, an anti-inflammatory agent. Studies have shown that products with these two ingredients increase time to flare and decrease incidence of flare (Weber et al., 2015), as well as improve quality of life (Weber et al., 2014).

In addition to preventing flares in patients diagnosed with AD, proactive use of moisturizers in high-risk neonates may reduce the risk of developing AD (Simpson et al., 2014). Results of this trial demonstrated that applying a daily full-body emollient (Aquaphor® Healing Ointment, 50% paraffin in white petrolatum, Cetaphil® cream, Doublebase® gel, or sunflower oil) therapy within 3 weeks of birth represents a feasible, safe, and effective approach for atopic dermatitis prevention. Although another study by some of the original investigators (McClanahan et al., 2019) showed a protective but nonsignificant effect of daily use of a therapeutic moisturizer, statistical significance was not reached, likely due to the second study being under-powered (McClanahan et al., 2019). If confirmed in larger trials, emollient therapy from birth would be a simple and low-cost intervention that could reduce the global burden of allergic diseases.

Patients, caregivers, and health care providers all over the world acknowledge the confusion about moisturizer information (Ersser et al., 2009). The ultimate selection of moisturizer for each patient should be individualized. Active ingredients, potential irritants and sensitizers, vehicles, absorption, amount required, cost, cosmetic appeal, patient preference, and the patient's willingness to use should all be taken into account. Given the thousands of products from which to select, patients appreciate specific provider recommendations to be assured of selection of an efficacious product. When and how moisturizers are to be used if other topicals are additionally prescribed should be specifically addressed. In general, studied moisturizers with proven ingredients and limited irritants and sensitizers are desired. Examples of some of the most recommended moisturizers for AD include Aquaphor® ointment, various Eucerin® formulations, Vanicream®, Vaniply®, CeraVe® formulations, and Cetaphil® cream.


Educational interventions have long been recommended and used as critical adjunct at all levels of therapy for patients with AD to enhance therapy effectiveness (Nicol & Ersser, 2010). These interventions may be directed toward adult patients or the parent/caregiver or child with eczema. Education also needs to take into account a shared decision-making approach, allowing patients and their families to have significant input with regard to specific choices when individualizing an AD care plan to promote compliance and success.

Individualized education includes teaching about the chronic or relapsing nature of AD, exacerbating factors, and therapeutic options with benefits, risks, and realistic expectations. This important educational facet of care management is becoming increasingly difficult to accomplish in routine care or clinic visits and seems to be equally difficult to measure and evaluate. Studies have shown that patients frequently fail to receive adequate explanation of the causes and triggers of AD, and are often not taught foundational skin care (Stalder et al., 2013). This occurs even though instruction and practical demonstrations have been associated with dramatic improvement in the treatment outcomes (Nicol, 2005b). Written handouts and resources are valuable to patients and families. Table 1 is an example of a simplified handout with basic instructions for fundamental skin care.

Beyond Basic AD Management

Comprehensive AD treatment regimens are implemented in a stepwise approach tailored to the individual patient and should be severity-based (see Figure 1) (Boguniewicz et al., 2008; Brar et al., 2019). This stepwise approach includes the foundational skin care discussed and then escalating to more potent anti-inflammatory treatments as the disease severity increases.

The second step of care is with low-to-medium potency topical corticosteroids (TCS) or other therapeutic agents, such as topical calcineurin inhibitors (TCI) (Nicol, 2011), or newer PDE4 inhibitors (Paller et al., 2016) may be initiated. During moderate-to-severe AD flares, the third step of care should minimally include moderate potency TCS, and are typically prescribed and may be used in conjunction with wet wrap therapy (WWT) (Nicol, 1987; Nicol & Boguniewicz, 2017). WWT is an effective adjuvant therapy in refractory or severe AD (Nicol et al., 2014). WWT uses a topical therapeutic agent covered first by a wet layer of occlusive bandages or tighter fitting, cotton clothes followed second by a similar dry outer layer. Detailed how-to instructions for WWT are available from the following publications (Brar et al., 2019; Nicol & Boguniewicz, 2008; Nicol & Boguniewicz, 2017).

The final step of care is for AD refractory to conventional forms of therapy. Use of alternative anti-inflammatory and immunomodulatory agents may be necessary, including the newly introduced biologics. This author and colleagues have a recent comprehensive article outlining the care of the patient with moderate-to-severe AD, including the new biologics (Brar et al., 2019).