New Canadian guidelines on managing atopic dermatitis with topical therapies

Atopic dermatitis (AD) is a chronic, relapsing immune-mediated inflammatory disease of the skin. It is characterized by intense pruritus, erythema, edema, excoriation, lichenification, oozing/crusting and/or dryness. AD typically begins in infancy or childhood and may continue into or first appear in adulthood. It affects about 15% of children and 4% of adults in Canada, with the majority of patients having mild-to-moderate disease severity. Optimal management of AD involves assessment of disease burden, education, nonpharmacologic measures to mitigate flares, topical therapy and sometimes systemic therapy. To optimize treatment guidance, a group of 10 Canadian dermatologists with expertise in AD management developed new consensus guidelines for management of AD with topical therapies. The guidelines outline generally accepted principles, provide consensus recommendations, and offer a practical treatment algorithm for AD management.Generally accepted principlesClinical disease severity in patients with AD can be assessed by body surface area (BSA), the Eczema Area and Severity Index (EASI) and the Investigator’s Global Assessment (IGA). The patient’s perspective can be assessed by the Dermatology Life Quality Index (DLQI), Patient-Oriented Eczema Measure (POEM), pruritus numerical rating scales, and sleep disturbance.When evaluating treatment options for AD, consider patient preference, age, sensitive areas, disease extent, chronicity, severity and patient-reported symptoms. It is important to involve the patient with AD in therapeutic decisions.Maintenance therapy is an essential part of the management of patients with AD.Noncorticosteroid topical therapies are generally not recommended for the treatment of AD in patients who are pregnant or breastfeeding.Consensus statementsDisease burden – For routine clinical practice, BSA, IGA and pruritus assessment are the most practical disease severity measures in patients with AD.Bleach baths and wet wraps—Bleach baths have been used as adjunctive therapy for AD, but are not recommended as their benefits are not supported by evidence. Wet wraps may be helpful for extensive or recalcitrant AD, but are impractical for routine use.Topical therapies:Topical corticosteroids should ideally be limited to short-term use in AD. If patient response is insufficient after four weeks of treatment, consider alternate therapeutic options.Noncorticosteroid topical therapies can be used for widespread involvement of AD according to approved use.Topical Janus kinase inhibitors (JAKi; ruxolitinib) do not have the same risk profile as topical corticosteroids in AD and may be used continuously for extended periods on all sites, including sensitive areas.Treatment with topical corticosteroids, topical calcineurin inhibitors (tacrolimus, pimecrolimus), topical phosphodiesterase-4 inhibitors (crisaborole, roflumilast), or topical JAKi is not advised in patients with AD who have an active skin infection unless they are receiving appropriate antimicrobial therapy.Off-label use of topical therapy in AD may be necessary to achieve the desired treatment outcomes. (For example, tacrolimus 0.1% ointment may be needed to control disease in children aged 2–15 years.)Topical JAKi can be used concomitantly with biologic therapies in the treatment of AD.Although treatments beyond topical therapies may be needed for refractory cases, the threshold for considering phototherapy and systemic therapies for AD may shift as a wider spectrum of AD disease may be responsive to treatment with novel noncorticosteroid topical therapies.Maintenance therapyMaintenance therapy provides an opportunity to prevent disease flares, maintain patient quality of life and reduce the need for topical corticosteroids. Twice-weekly application of a topical anti-inflammatory agent will likely reduce the incidence of flares. Twice-daily topical corticosteroids should be limited to intermittent short-term use due to safety issues. Tacrolimus (0.03% and 0.1% ointment), applied once daily twice per week, is indicated for maintenance therapy in patients with a high frequency of flares (e.g., at least 5 flares/year). Ruxolitinib (1.5% cream) can be resumed at the first sign of recurrence and stopped three days after signs/symptoms have resolved. Patients with frequent recurrence despite maintenance therapy may be candidates for systemic therapy.Treatment algorithmThe consensus guidelines include an algorithm for the topical therapy of AD in infants (3 months to 2 years), children (2 to < 12 years), adolescents (12 to < 16 years) and adolescents/adults (≥ 16 years). The algorithm summarizes education and general measures, treatment considerations, initial therapy (based on disease severity), maintenance therapy and assessment of response after four to six weeks of therapy. Reference:Gooderham MJ, Hong HC, Lynde C, et al. Canadian consensus guidelines for the management of atopic dermatitis with topical therapies. Dermatol Ther 2025; published April 25, 2025 online ahead of print. (accessed May 1, 2025).

New Canadian guidelines on managing atopic dermatitis with topical therapies

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