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derm.atopic-dermatitis.core.v1PRODUCTION
derm.atopic-dermatitis.core.v1

Atopic dermatitis (eczema)

dermatologychronicsubacuteadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC relapsing type-2 barrier disease managed on a barrier-first + stepwise anti-inflammatory ladder, NOT a one-off rash. Acute complications (eczema herpeticum, impetiginised eczema, erythroderma) are recognised here and routed/escalated. The not-to-miss is adult treatment-resistant "eczema" = CTCL until biopsy says otherwise.

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chronic AD framing set; complication + CTCL escape routes noted

Patient inputs (16)

New-onset adult "eczema" that is treatment-resistant / atypical → biopsy to exclude cutaneous T-cell lymphoma (mycosis fungoides) before chronic immunosuppression (AAD 2023 PMID 37943240)

Age-typical distribution (infant face/extensor; child/adult flexural; adult hand/head-neck) supports criteria; nodular/linear/geometric argues a mimic (UK Working Party; AAD 2023 PMID 36623556)

Asthma/allergic-rhinitis/food-allergy/eosinophilic-esophagitis co-management; type-2 burden favours an IL-4/13-axis biologic (AAD 2022 PMID 35085682)

True topical failure (adequate potency/quantity/adherence for ≥4-6 wk) vs under-treatment determines whether to escalate or optimise (AAD 2023 PMID 37943240)

Pruritus is the defining symptom and the primary patient-reported outcome (Peak Pruritus NRS) that drives step-up decisions (AAD 2023 PMID 37943240)

Weeping/honey-crust/pustules → S. aureus impetiginisation; monomorphic punched-out erosions → eczema herpeticum (route urgently) (AAD 2023 PMID 36623556)

>90% BSA erythema = erythrodermic flare — thermoregulatory/fluid risk, admission threshold, CTCL/Sézary consideration

BSA + intensity + itch + QoL define mild/moderate/severe and gate topical-vs-systemic escalation (AAD 2023 systemics PMID 37943240)

Pediatric dosing + agent age-cutoffs (TCI ≥2 y, ruxolitinib ≥12 y, dupilumab ≥6 mo); age ≥65 JAK MACE/VTE caution (ORAL Surveillance extrapolation) (AAD 2023 PMID 37943240)

JAK baseline + monitoring (cytopenia); eosinophilia (atopy vs hypereosinophilic/CTCL-Sézary differential) (AAD 2023 PMID 37943240)

JAK / methotrexate / cyclosporine baseline + on-treatment hepatotoxicity monitoring (AAD 2023 PMID 37943240)

Pre-systemic latent-TB + hepatitis screen before JAK / immunosuppressant initiation (AAD 2023 PMID 37943240)

JAK-class dyslipidaemia monitoring at 4-12 wk then periodically (AAD 2023 PMID 37943240)

JAK inhibitors / methotrexate / mycophenolate contraindicated in pregnancy; dupilumab generally continued; gates the systemic ladder (AAD 2023 PMID 37943240)

JAK boxed warning — VTE/MACE/malignancy; prior VTE/MI/active-smoker/age≥65 shifts selection toward a biologic (AAD 2023 PMID 37943240)

Cyclosporine nephrotoxicity + JAK renal dose-adjust; CKD-EPI 2021 race-free eGFR (AAD 2023 PMID 37943240; Inker NEJM 2021)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (7)

7 need judgement
  • informationallife_threateningeczema_herpeticum_emergency
    Acute monomorphic punched-out vesicles/erosions, fever, pain, malaise (± periocular) on a background of eczema — HSV superinfection (Kaposi varicelliform eruption)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereerythrodermic_ad_flare
    >90% BSA confluent erythema ± scaling with impaired thermoregulation / fluid loss / haemodynamic stress
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateimpetiginised_eczema
    Honey-coloured crust, pustules, weeping, rapid worsening — S. aureus impetiginisation of eczema
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateadult_treatment_resistant_biopsy_for_ctcl
    New-onset adult "eczema" that is fixed, poikilodermatous, atypical, or resistant to adequate therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatejak_high_risk_prefer_biologic
    Candidate for systemic therapy with prior VTE/MI/stroke, active smoking, or age ≥65
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepregnancy_systemic_gating
    Pregnant/conceiving patient requiring systemic AD therapy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildtopical_failure_is_undertreatment
    Reported topical "failure" without an adequate trial (insufficient potency/quantity/duration or TCS-phobia non-adherence)
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENToptionalDrives dose adjustment
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Recommended regimen

Atopic dermatitis — barrier-first + stepwise anti-inflammatory ladder (AAD 2023/2025)
axis: ad_stepwise_barrier_first_ladderstep 1 - Step 1 — Barrier foundation (every patient, every step, lifelong)
Selected step "Step 1 — Barrier foundation (every patient, every step, lifelong)" — All severities, continuously — the non-negotiable substrate beneath every anti-inflammatory step
  • emollient_moisturiser_high_volume
    first line
    barrier_repair
    AAD 2023 topicals (PMID 36623556) STRONG rec — liberal moisturiser (~250 g/wk adult) reduces flares, itch, and TCS requirement; apply within 3 min of bathing (soak-and-seal).
  • trigger_mitigation_and_bathing_practices
    first line
    barrier_repair
    AAD 2023 (PMID 36623556) — gentle non-soap cleanser, lukewarm short baths + immediate emollient; conditional bleach baths for recurrently infected eczema; mitigate irritants/aeroallergens/sweat/stress.
  • wet_wrap_therapy_for_acute_flare
    rescue
    barrier_repair
    triggers: acute_severe_flare, recalcitrant_localised_disease
    AAD 2023 (PMID 36623556) conditional — wet wraps over diluted TCS for acute severe flares rapidly cool/hydrate and boost topical delivery.

outpatient playbook — drug actions (4)

  1. 1. emollient + soak-and-seal + trigger mitigation (foundation)
    ~250 g/wk • topical • daily, lifelong
    trigger: All patients, all severities (AAD 2023 PMID 36623556)
    Barrier repair reduces flares, itch, and steroid requirement
  2. 2. triamcinolone 0.1% (flare) → twice-weekly proactive
    rxcui 10759
    0.1% • topical • BID flare then 2×/wk
    trigger: Active mild–moderate flare (AAD 2023 PMID 36623556)
    Potency matched to site/severity; proactive maintenance halves relapse
  3. 3. tacrolimus 0.1% / crisaborole 2% (steroid-sparing, face/folds)
    rxcui 42316
    0.1% / 2% • topical • BID
    trigger: Face/fold disease or steroid-sparing maintenance (AAD 2023 PMID 36623556)
    Avoids steroid atrophy at sensitive sites; proactive maintenance
  4. 4. dupilumab (first-line systemic) or oral JAK if rapid control / JAK-eligible
    rxcui 1876376
    300 mg q2wk • SC • q2wk
    trigger: Topical/phototherapy-refractory or high QoL burden (AAD 2023 PMID 37943240)
    Biologic favourable long-term safety + dual-indication; JAK fastest but boxed warning

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Chronic / relapsing intensely pruritic eczematous rash in a flexural (adult/child) or facial-extensor (infant) distribution (UK Working Party criteria; AAD 2023 topicals exec PMID 36623556); Personal/family atopy (asthma, allergic rhinitis, food allergy — the atopic march) (AAD 2022 comorbidities PMID 35085682); Itch-dominant, sleep-disrupting disease with itch–scratch–lichenification cycle (AAD 2023 topicals PMID 36623556).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Atopic dermatitis (eczema)** (derm.atopic-dermatitis.core.v1).
Phenotype framing: Terminal eczematous differential with named pivots: AD vs allergic contact dermatitis (geometric margin + patch-test pivot) vs irritant contact dermatitis (exposure + burning>itch pivot) vs seborrheic dermatitis (greasy scale + scalp/nasolabial pivot) vs psoriasis (sharp salmon plaque + silver scale + Auspitz pivot) vs scabies (burrow + web-space + contact itch pivot) vs nummular eczema (coin lesions pivot) vs tinea corporis (KOH+ annular advancing scale pivot) vs CTCL/mycosis fungoides (fixed poikilodermatous patches + biopsy pivot) vs drug eruption (temporal drug link pivot — route derm.drug-eruption.core.v1).
Scope: Frame as a CHRONIC relapsing type-2 barrier disease managed on a barrier-first + stepwise anti-inflammatory ladder, NOT a one-off rash. Acute complications (eczema herpeticum, impetiginised eczema, erythroderma) are recognised here and routed/escalated. The not-to-miss is adult treatment-resistant "eczema" = CTCL until biopsy says otherwise.

No severity triggers fired against current inputs.

Plan

Regimen axis: **Atopic dermatitis — barrier-first + stepwise anti-inflammatory ladder (AAD 2023/2025)** — step "Step 1 — Barrier foundation (every patient, every step, lifelong)".
1. emollient_moisturiser_high_volume (barrier_repair, first line) — AAD 2023 topicals (PMID 36623556) STRONG rec — liberal moisturiser (~250 g/wk adult) reduces flares, itch, and TCS requirement; apply within 3 min of bathing (soak-and-seal).
2. trigger_mitigation_and_bathing_practices (barrier_repair, first line) — AAD 2023 (PMID 36623556) — gentle non-soap cleanser, lukewarm short baths + immediate emollient; conditional bleach baths for recurrently infected eczema; mitigate irritants/aeroallergens/sweat/stress.
3. wet_wrap_therapy_for_acute_flare (barrier_repair, rescue) — AAD 2023 (PMID 36623556) conditional — wet wraps over diluted TCS for acute severe flares rapidly cool/hydrate and boost topical delivery.

Setting playbook (outpatient) — Confirm clinical AD (exclude mimics + CTCL), establish barrier-first care + proactive maintenance, escalate the anti-inflammatory ladder to disease severity, and gate systemic agent choice on pregnancy/age/thrombotic/comorbidity status (AAD 2023 PMID 36623556 + 37943240; AAD 2025 PMID 40531067)
4. emollient + soak-and-seal + trigger mitigation (foundation) ~250 g/wk topical daily, lifelong — All patients, all severities (AAD 2023 PMID 36623556) (Barrier repair reduces flares, itch, and steroid requirement)
5. triamcinolone 0.1% (flare) → twice-weekly proactive 0.1% topical BID flare then 2×/wk — Active mild–moderate flare (AAD 2023 PMID 36623556) (Potency matched to site/severity; proactive maintenance halves relapse)
6. tacrolimus 0.1% / crisaborole 2% (steroid-sparing, face/folds) 0.1% / 2% topical BID — Face/fold disease or steroid-sparing maintenance (AAD 2023 PMID 36623556) (Avoids steroid atrophy at sensitive sites; proactive maintenance)
7. dupilumab (first-line systemic) or oral JAK if rapid control / JAK-eligible 300 mg q2wk SC q2wk — Topical/phototherapy-refractory or high QoL burden (AAD 2023 PMID 37943240) (Biologic favourable long-term safety + dual-indication; JAK fastest but boxed warning)

Non-pharmacologic actions:
- Written eczema action plan (green/yellow/red flare steps) + fingertip-unit quantity education (AAD 2023 PMID 36623556)
- TCS-phobia counselling to prevent under-treatment (the commonest cause of "topical failure")
- Bleach-bath protocol for recurrently infected eczema (AAD 2023 PMID 36623556, conditional)
- nbUVB referral for moderate topical-refractory disease deferring systemics (AAD 2023 PMID 37943240)

AVOID / contraindication checks:
- Jak boxed warning vte mace malignancy serious infection (AAD 2023 PMID 37943240 — prefer a biologic if prior VTE/MI/stroke, active smoker, or age ≥65; ORAL Surveillance extrapolation)
- Jak methotrexate mycophenolate contraindicated in pregnancy (AAD 2023 PMID 37943240 — dupilumab is the preferred systemic in pregnancy)
- Cyclosporine nephrotoxicity hypertension limit to short term (AAD 2023 PMID 37943240 — ≤1 y; monitor BP + creatinine)
- Against chronic systemic corticosteroids (AAD 2023 PMID 37943240 — rebound + cumulative harm)
- Against routine topical antimicrobials and topical antihistamines (AAD 2023 PMID 36623556)
- Live vaccines avoided on biologic or jak immunosuppression
- Eczema herpeticum is an emergency not treated by escalating immunosuppression (urgent systemic aciclovir + route)

Monitoring

Regimen monitoring:
- itch NRS plus BSA IGA QoL sleep at 4-16wk (AAD 2023 PMID 37943240 — biologic effect by 12-16 wk; oral JAK days-weeks)
- JAK: CBC + LFT + lipids at ~4-12 wk then periodic; VTE/MACE/zoster vigilance (AAD 2023 PMID 37943240)
- cyclosporine: BP + creatinine q2wk during titration (AAD 2023 PMID 37943240)
- methotrexate: CBC + LFT periodic; folic acid co-prescribed (AAD 2023 PMID 37943240)
- dupilumab: conjunctivitis + facial/neck erythema surveillance — no routine labs (AAD 2023 PMID 37943240)
- proactive twice weekly maintenance adherence and emollient quantity (AAD 2023 PMID 36623556)

Setting (outpatient) monitoring:
- Reassess itch NRS + BSA/IGA + QoL at 4-16 wk per agent (AAD 2023 PMID 37943240)
- Drug-class safety labs on schedule (JAK CBC/LFT/lipids; cyclosporine BP/Cr; MTX CBC/LFT) (AAD 2023 PMID 37943240)

Follow-up plan: Chronic-disease maintenance: lifelong emollient/barrier habit + written eczema action plan (green/yellow/red flare steps), proactive twice-weekly anti-inflammatory to recurrence-prone sites, trigger control, atopic-march + mental-health + sleep + comorbidity surveillance (AAD 2022), education on quantity (fingertip unit) and TCS-phobia counselling, and step-down/step-up criteria. Dermatology continuity for any systemic agent; reassess CTCL if course remains atypical.
- Close-out criterion: action plan + proactive maintenance + comorbidity surveillance + education documented

Monitoring phase: Disease: itch NRS + BSA/IGA + QoL/sleep at 4-16 wk to judge step response (biologic effect by 12-16 wk; oral JAK faster, days-weeks). Drug safety: JAK → CBC, LFT, lipids at ~4-12 wk then periodic, VTE/MACE/zoster vigilance; cyclosporine → BP + creatinine q2wk during titration; methotrexate → CBC/LFT; biologics → conjunctivitis (dupilumab), injection-site, rare facial erythema. Watch tachyphylaxis/under-dosing and proactive-maintenance adherence.

Disposition

Current setting: outpatient — Confirm clinical AD (exclude mimics + CTCL), establish barrier-first care + proactive maintenance, escalate the anti-inflammatory ladder to disease severity, and gate systemic agent choice on pregnancy/age/thrombotic/comorbidity status (AAD 2023 PMID 36623556 + 37943240; AAD 2025 PMID 40531067)

Disposition criteria:
- Continue ladder + proactive maintenance + derm follow-up if responding (AAD 2023 PMID 37943240)
- Step up the ladder if adequate trial fails after adherence/trigger optimisation
- Admit only for eczema herpeticum with systemic illness, severe erythroderma, or superinfection failing oral therapy

Escalation triggers (move to higher acuity):
- Eczema herpeticum (monomorphic punched-out erosions + fever) → urgent systemic aciclovir + ophthalmology if periocular + route OUT (dermatologic emergency)
- Erythrodermic flare >90% BSA with systemic compromise → admit
- Adult treatment-resistant/atypical disease → skin biopsy for CTCL before chronic immunosuppression (AAD 2023 PMID 37943240)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute monomorphic punched-out vesicles/erosions, fever, pain, malaise (± periocular) on a background of eczema — HSV superinfection (Kaposi varicelliform eruption)
- [SEVERE] >90% BSA confluent erythema ± scaling with impaired thermoregulation / fluid loss / haemodynamic stress
- [MODERATE] Honey-coloured crust, pustules, weeping, rapid worsening — S. aureus impetiginisation of eczema

Citations

- AAD 2023 Guidelines of care for AD — topical therapies (Sidbury et al, JAAD; exec PMID 36623556) + phototherapy & systemic therapies (Davis et al, JAAD; PMID 37943240, exec 37943241) + AAD 2025 focused update (Davis et al, JAAD; PMID 40531067: tapinarof, roflumilast, lebrikizumab, nemolizumab) + AAD 2022 comorbidities (Davis et al, JAAD; PMID 35085682) + AAD/AAAAI-ACAAI JTF 2023-24 concordance review (PMID 41416235) [PMID:36623556](https://pubmed.ncbi.nlm.nih.gov/36623556/)
- Cited evidence (PMID 37943240) [PMID:37943240](https://pubmed.ncbi.nlm.nih.gov/37943240/)
- Cited evidence (PMID 37943241) [PMID:37943241](https://pubmed.ncbi.nlm.nih.gov/37943241/)
- Cited evidence (PMID 40531067) [PMID:40531067](https://pubmed.ncbi.nlm.nih.gov/40531067/)
- Cited evidence (PMID 35085682) [PMID:35085682](https://pubmed.ncbi.nlm.nih.gov/35085682/)

Last reconciled with current guidelines: 2026-05-22.
References
  • AAD 2023 Guidelines of care for AD — topical therapies (Sidbury et al, JAAD; exec PMID 36623556) + phototherapy & systemic therapies (Davis et al, JAAD; PMID 37943240, exec 37943241) + AAD 2025 focused update (Davis et al, JAAD; PMID 40531067: tapinarof, roflumilast, lebrikizumab, nemolizumab) + AAD 2022 comorbidities (Davis et al, JAAD; PMID 35085682) + AAD/AAAAI-ACAAI JTF 2023-24 concordance review (PMID 41416235) — PMID:36623556
  • Cited evidence (PMID 37943240) — PMID:37943240
  • Cited evidence (PMID 37943241) — PMID:37943241
  • Cited evidence (PMID 40531067) — PMID:40531067
  • Cited evidence (PMID 35085682) — PMID:35085682