The symptoms of atopic dermatitis vary widely from child to child: while some affected individuals only have mild skin problems and occasional itching, others suffer from severely inflammatory eczema all over the body. Using a stepwise approach, the current course of atopic dermatitis can be better assessed, and a tailored therapy can be recommended. This prevents one from resorting to strong medications too early or conversely receiving a therapy that is too weak.

Basis of Atopic Dermatitis Therapy

Regardless of the severity, all affected individuals should take certain basic measures to protect and strengthen the skin:

1. Skin care: A re-oiling basic care (creams, ointments, lotions) helps repair the disturbed protective layer of the skin.

2. Avoiding triggers: Stress, inappropriate clothing (e.g., scratchy wool) and certain environmental factors can trigger flare-ups. A diary can help identify individual triggers.

3. Adjusted personal hygiene: Short, lukewarm shower or bath sessions, mild shower gels or bath additives, possibly medical oil baths.

These basic steps form the foundation – regardless of whether the atopic dermatitis is mild or severe.

Step 1: Dry Skin

In a mild form, the symptoms are still manageable: the skin is dry, feels a bit tight, and there may be small eczema spots that can itch.

Treatment focuses:

• Daily basic care (re-oiling creams or lotions)

• Avoiding mechanical irritation (scratchy fabrics, intense scratching)

• Possibly weak corticosteroid creams (low potency) on inflamed areas

The goal is to alleviate itching and stabilize the skin barrier so that larger eczema do not develop.

Step 2: Mild / Moderate Eczema

If increased eczema, redness, and severe itching occur, it is referred to as moderately severe atopic dermatitis. In addition to basic care, more intensive measures are now employed:

• Topical corticosteroids of medium potency: If necessary, steroid-containing creams or ointments are applied to the inflamed areas, but for a limited time.

• Topical calcineurin inhibitors (e.g., tacrolimus, pimecrolimus): These work similarly anti-inflammatory to corticosteroids but are usually somewhat weaker. However, they do not have an atrophic effect (thinning of the skin). They are particularly used in sensitive skin areas (e.g., face, genital area).

• Accompanying measures: Special dressings like fat-moist compresses can soothe the skin inflammation and itching.

  
  

Step 3: Moderate / Severe Eczema

In severe atopic dermatitis, widespread eczema occur with unbearable itching and sometimes also crusted or hardened skin areas. Here, the quality of life is often severely impaired.

• Intensive local therapy: Highly effective corticosteroids, possibly calcineurin inhibitors in combination.

• Phototherapy (light therapy): Narrowband UVB can help reduce inflammation. However, it is now rarely performed (in children).

• Systemic medications:

  • Immunosuppressants (e.g., ciclosporin, methotrexate) can be used short-term when local therapies are insufficient. The use in children is only in exceptional cases, especially since biologics have become available.

  • Biologics (e.g., dupilumab): Highly effective, modern therapy with a safe side effect profile. Biologics block certain inflammatory mechanisms in the body. They offer new opportunities, especially in severe, therapy-resistant atopic dermatitis.

  
  

Conclusion

The stepwise approach in atopic dermatitis offers a structured way to tailor therapy to individual needs. From consistent basic care and weaker steroid-containing creams for mild atopic dermatitis to biologics for severe cases – the aim is always to alleviate eczema, reduce itching, and improve quality of life.

Sources

1. AWMF (2024). S3 Guidelines Atopic Dermatitis.