Choosing the Right Topical Therapy for Patients With Atopic Dermatitis (AD): Balancing Risk and Efficacy

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