Moisturizer is the lifelong cornerstone of AD care — not just during acute flares, but Daily. AAD 2023 strongly recommends (Grade A evidence) using ≥ 250 g of moisturizer per week, which reduces acute flare frequency by about 30–50%."Soak and seal" principle: shower ≤ 10 min + lukewarm water + no soap scrubbing + apply moisturizer + topical medication within 3 min of toweling — works best. Newer non-steroidal topicals (PDE4i, topical JAKi, tapinarof, roflumilast) help with special sites, long-term maintenance, and reduce steroid use possible.
Foundation 1: Daily moisturizer
AAD 2023 strong A-level: ≥ 250 g/week, soak-and-seal (10-minute lukewarm bath, syndet not soap, then moisturizer within 3 minutes). Ointments > creams > lotions. Daily infant moisturizer reduces AD development by ~50%.
Foundation 2: Topical corticosteroids
Class 1-7 by potency. Use appropriate-strength TCS BID for 7-14 days during flares, then proactive maintenance (twice weekly). FTU dosing: 1 FTU = 0.5 g covers 2 adult palms. Avoid steroidophobia — adequate short-term TCS plus proactive maintenance results in less cumulative steroid exposure than under-treatment with repeat flares.
Topical calcineurin inhibitors (TCI)
Tacrolimus 0.03–0.1% ointment, pimecrolimus 1% cream. Best for face, eyelids, intertriginous; long-term proactive maintenance. Initial burning/stinging usually resolves; chill the tube, pre-apply moisturizer. FDA black-box warning not supported by long-term registry data.
Newer non-steroid topicals (post-2017)
- Crisaborole 2% ointment (Eucrisa) — PDE4 inhibitor; BID; mild-moderate AD; ≥ 3 months age.
- Ruxolitinib 1.5% cream (Opzelura) — topical JAK1/2 inhibitor; BID × 8 weeks; EASI-75 ~53%, IGA 0/1 ~50% — comparable to mid-potency steroid; FDA-approved, not yet in Taiwan.
- Tapinarof 1% cream (Vtama) — AhR modulator; QD; FDA-approved 2024 for AD.
- Roflumilast 0.15% cream (Zoryve) — strong PDE4 inhibitor; QD; FDA-approved 2024 for AD.
Wet wrap therapy
For severe acute flares (especially children): bath, apply low-mid TCS + emollient, wet inner cotton layer, dry outer cotton layer, wear 2-12 hours. 3-7 days reduces EASI dramatically.
Bathing & bleach baths
Daily ≤ 10 min lukewarm baths, syndet cleansers (pH 5.5, no SLS). Dilute bleach bath (¼–½ cup of 6% bleach in a tub, ≈ 0.005% NaOCl) twice weekly reduces Staphylococcus aureus colonization (AAD 2023 conditional).
Practical treatment ladder
Daily moisturizer always. Mild flare: low-mid TCS or TCI 7-14d. Moderate: mid-potent TCS + adjunct (ruxolitinib/crisaborole). Severe: potent TCS + wet wrap + bleach bath + consider systemic. Maintenance: TCI/PDE4i/topical JAK twice-weekly proactive.
Bottom line
"Daily moisturizer + adequate TCS during flares + proactive maintenance with non-steroid topicals" is the modern foundation. Step up to systemic therapy if 4-8 weeks of consistent topical care fails.