Atopic Dermatitis Treatment for New NPs (Updated 2026)
Atopic dermatitis can be SO painful for patients and their families. It can feel frustrating for both the patients and providers when they keep coming back without getting any better. Patients may be dealing with constant itching, poor sleep, frequent flares, and a long list of products they’ve already tried without much success.
In this episode, I walk through a practical approach to managing atopic dermatitis in primary care, with a focus on what actually helps patients day-to-day: restoring the skin barrier, treating flares appropriately, breaking the itch-scratch cycle, recognizing secondary infection, and knowing when it’s time to refer.
2026 Update: Originally published in 2020 and reviewed for clinical accuracy in 2026. The core approach to atopic dermatitis in this episode remains current. Updates include current guidance on bleach baths, antihistamines, topical corticosteroid duration and potency, and proactive maintenance treatment. See the Clinical Updates as of 2026 below the video. For the current, point-of-care version of this guidance, see the Atopic Dermatitis Cheat Sheet in the Digital NP Binder.
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What I Covered in this Episode:
Daily skincare and restoring the skin barrier
How to manage eczema flares and the itch-scratch cycle
How to choose topical corticosteroid potency based on body area
Wet wraps, bleach baths, and other adjunctive treatments
How to recognize secondary infection
When to consider food allergy evaluation or dermatology referral
Clinical Updates as of 2026
Update: The evidence and rationale for bleach baths have evolved. In the original episode, I discuss dilute bleach baths primarily as a way to reduce bacterial colonization in patients with eczema and recurrent skin infections. Current guidance supports bleach baths as an adjunct for moderate-to-severe atopic dermatitis, but their benefit may be related more to anti-inflammatory effects than directly reducing S. aureus on the skin.
Correction: Antihistamines aren't routinely recommended to treat itch from atopic dermatitis. Although antihistamines can relieve histamine-mediated itching, eczema itch is driven by multiple pathways and generally doesn't respond well to antihistamines. In the original episode, I discuss hydroxyzine as part of breaking the itch/scratch cycle. A sedating antihistamine such as hydroxyzine may still be considered short-term at bedtime when severe itching is disrupting sleep, but its main role is helping with sleep while the underlying eczema is treated.
Correction: There is not a universal “15 days per month” limit for topical corticosteroids. Treatment duration depends on potency, body site, age, and response. Active disease is generally treated for a defined course until controlled, with shorter courses of stronger steroids on sensitive areas.
Maintenance treatment can now include proactive anti-inflammatory therapy. In the episode, I focus primarily on daily moisturization between flares and topical corticosteroids during active flares. For patients who repeatedly flare in the same areas, current guidance also supports intermittent topical corticosteroid or calcineurin inhibitor treatment to previously affected areas, typically 2–3 days per week, to help prevent recurrence.
Key Takeaways as of 2026
Treat the skin barrier every day, not just during flares. Regular moisturization and gentle skin care are a foundational part of treatment and can reduce itch, flares, and the need for topical corticosteroids.
Think in terms of maintenance + flare treatment. Atopic dermatitis is chronic and relapsing, so patients need a plan for both keeping the skin controlled and managing worsening symptoms when they occur.
Use topical corticosteroids intentionally. Choose potency based on severity, patient age, and body site rather than using the same steroid everywhere. The face, folds, and young children generally need lower-potency treatment, while thicker or more resistant areas may require stronger therapy.
For recurrent flares in the same areas, think proactively. Intermittent topical corticosteroid or calcineurin-inhibitor therapy to previously affected areas can help prevent relapse.
Watch for infection instead of assuming every worsening flare is “just eczema.” New crusting, drainage, pustules, tenderness, rapidly worsening erythema, or systemic symptoms should prompt evaluation for secondary infection.
Don’t reflexively order food allergy testing. Food sensitization is common in children with AD, but true food-triggered worsening of eczema is much less common, and broad testing or elimination diets can create unnecessary restriction.
If the patient isn’t improving, reassess the plan before simply escalating. Check adherence, whether they have enough medication, ongoing triggers, possible infection, whether the diagnosis is correct, and whether they need dermatology referral.
Want a Quick Reference for Managing Atopic Dermatitis?
The Atopic Dermatitis Cheat Sheet gives you the info you need on hand for an atopic dermatitis visit, including guidance on daily skin care and moisturization, treating flares, choosing topical steroid potency by patient and body area, managing the itch-scratch cycle, wet wraps and dilute bleach baths, and recognizing secondary infection. Get the Atopic Dermatitis Cheat Sheet in the Digital NP Binder.
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WEBVTT
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Hey there, welcome to the Real World NP podcast. I'm Liz Rohr, family nurse practitioner, educator,
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and founder of Real World NP, an educational company for nurse practitioners in primary
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care. I'm on a mission to equip and guide new nurse practitioners so that they can
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feel confident, capable, and take the best care of their patients. If you're looking for clinical
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pearls and practice tips without the fluff, you're in the right place. Make sure you subscribe and
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leave a review so you won't miss an episode. Plus, you'll find links to all the episodes
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with extra goodies over at realworldnp.com slash podcast. So I have a confession to make,
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and actually I'm sure that you have this as well. There are certain topics that I'm just
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not as excited about. I really like the intricate diagnostic puzzles and atopic dermatitis is not
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necessarily one of them. Hold that thought though, because dermatology is hard, but
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eczema may or may not be easier to diagnose than some other ones, but the real magic comes in
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the treatment. Because I think that as a community, as a profession, we don't necessarily serve
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our eczema patients to the highest level that we could. And I did some CEUs recently and I
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wanted to share all these beautiful pearls that I got in my own care, especially, I mean,
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I don't know if you've ever been in this situation, but I frequently get little kiddos,
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this applies to adults too, by the way, but little kiddos that are coming in, the parents
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are just exhausted and near tears, the kids are crying the whole visit, they're covered
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in eczema. You have a huge role to help those kinds of people, and this happens all the
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time in my family practice clinic. So if you're new here, I'm Liz Rohr from Real World NP,
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and you're watching NP Practice Made Simple, the weekly videos to help save you time,
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frustration, and help you learn faster so you can take the best care of your patients. So in this
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video, I'm going to be breaking it down with some really helpful paradigms and insights and
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clinical pearls to really practically apply to your care of these patients, knowing when to
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refer them to dermatology, the care that they should be doing at home, and answering
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questions like what creams to use and what allergies you should be testing for, like all
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that stuff. So stick around, I'm going to share my screen with you.
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So eczema has a huge impact on the quality of life. I just want to start with this because
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I think it really helps you if you haven't experienced those, you know, that screaming
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baby or the adult that comes in asking you again for the injectable steroids that their
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dermatologist gives them when they have eczema flares. Like I just want to paint this
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picture for you of how distressing this is as a diagnosis, as a condition rather. So most
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patients have daily itching and it sounds like a minor symptom, right? But it can drive
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people absolutely crazy. It also impairs their sleep and I think that's especially
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important for kiddos, for babies that are up crying all night and the parents are
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exhausted or the kids that aren't performing well in school because they're not sleeping
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well. Also, school-age kids can have things like lack of self-esteem, bullying, impaired
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school performance due to lack of sleep or related to the other issues that are
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coming up for them. It's exhausting and a lot of parents feel really inadequate because
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they feel like they can't get a handle on it, they can't get control over it and
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it's just a lot of maintenance and you're going to see that in a second. A lot of
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patients come in and they'll say, we've tried everything and I've definitely
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encouraged, experienced that myself. So something you want to think about. A lot of
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times it's like primary care clinicians are throwing spaghetti against the wall and
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I feel like that's kind of what I was doing as well even though I kind of
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understood how to treat eczema but hold on and we'll go through it. The main point
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with that is that we need to try things in the right combination and that's like
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my main takeaway of what I've learned and I think that that gives patients a lot
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of hope and hopefully it will give you a lot of hope too putting this all
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together. And before I go any further there's a cheat sheet down below this
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video if you want to download that to follow along with this presentation and
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also to keep at your desk for quick reference. So eczema, it's really important
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to think about it as a lifelong roller coaster. I've always said to my patients
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this is a chronic illness, it's not going to go away but I think when you
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paint the picture of like it is a roller coaster for everybody there's
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guaranteed ups and downs and it's, people try their best to
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maintain it but in some ways it's out of our hands you know that when
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things have flares and so I think if you set the expectation of like
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it's gonna be like this that can be a little bit easier as well. And then
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I think a helpful reframe that I've kind of learned for myself is that it's
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similar to asthma in that there's flared rescue treatment as well as the
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maintenance care and the maintenance care is so key and I think that it's
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also the most exhausting part so you'll see that in a second. Also the
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main thing about when it comes to eczema is about
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breaking that itch scratch cycle when it comes to flares which I'll talk
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about in a second so just stick with me. And then treatment for eczema works
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best when it's used consistently and all at the same time but it can again be
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hard and it can be exhausting. So the goals of care so number one is all
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about maintaining and repairing the skin barrier and so the main thing is
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moisturizing with emollients but we'll talk about the other skin care and
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that is like the underlying ultimate key because when you protect that skin
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barrier then it tends to there's just like a lot of research that
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supports that it can have so many positive effects and reduces the
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risks of further flares and other complications and on a very very small
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level too. Number two is again controlling the itch because when you
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have patients that are itching it's gonna make it worse and it's just
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gonna get into this nasty cycle. Helping with sleep that's got to be a
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really important component to your treatment. Treating and preventing
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infection which I'll talk about just kind of being mindful of when it's
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infection and when it's not. And then treating flares and inflammation
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on a kind of a preventative basis so stick with me and we'll talk
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about all these things so maintenance care. So this is gonna look like a lot
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but it's not that bad. It really comes down to skin care and avoiding triggers
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so skin care is daily use of emollients so hold that thought we'll talk about
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that but basically it just means creams that are thick enough that you
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can't use a pump because if you're using a pump those are more like
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lotions and they're not typically enough to be considered an emollient.
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It's important that they're hypoallergenic fragrance and dye
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and daily bathing there's been some confusion and controversy whether or not
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patients should kind of go every other day with their bathing versus daily
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bathing and I think the general recommendation in now is that you know
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and it depends you have to work with your family right so if they're
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insistent of like you know what this is what works for me like that's fine
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you know like this is a there's a couple of moving parts here right so
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but yeah it's generally recommended that they do daily bathing ten minutes
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of lukewarm water but the most important thing is that you're
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adding them dry and quickly applying emollient like right afterwards.
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Bleach baths are another component of skin care maintenance and we'll talk
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about that in just one second. Wet wraps which another is another like
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terrifying like thought or phrase and but hold on for a second and we'll
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talk about that hopefully I can empower you to recommend this to your
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families and make a big impact in their lives and again avoiding
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allergens and triggers and so the main kind of triggers that we can be
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controlling of is things like low humidity, sweat, friction, and saliva
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that's a little bit harder with the babies because they just they drool and
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drool but just knowing that that's an irritant and then potential topical
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allergens and so I think myself personally I get a little overwhelmed
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with this sometimes because the dermatologist that I was learning
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from kind of like spewed off this like really long chemical name that
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she was familiar with that was within a certain number of lotions
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and creams and all this stuff and I don't know I don't think that that's
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the expectation that we know all those things in primary care I definitely
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covet that level of knowledge but I think it's just important to think
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about like what are they noticing that seems to get worse or are there
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certain soaps or dyes or things like that. So that's maintenance care
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that's kind of a lot but basically it comes down to daily bathing
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emollients and then some other extra add-ons like those bleach baths
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and wet wraps which I'll talk about in a second and then flare
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treatment is typically when you're going to see them in primary care
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but you need to encourage the maintenance treatment. So it's the same
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skincare but you want to put out the fire and you want to add things
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like topical steroids which I have another slide on that so just hold
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that thought. You want to stop the itch and scratch cycle so the
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steroids are going to help with that but you're also going to consider
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adding an antihistamine and so the dosing for that I feel a little
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hesitant with this myself because I don't like giving antihistamines
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to little kids but hydroxazine like if they're up all night itching
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and scratching like that's going to help them break that cycle.
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Right. And so the dosing that was recommended was hydroxazine
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half a milligram per kilogram during the day and then one
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milligram per kilogram dosing at night as needed. And again wet
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wraps which I'll talk about in a second. And then in terms of
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asking the kiddos not to scratch like that doesn't work. So you
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have to think about all these other things and cool and cold
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packs can definitely help with itching as well as distraction.
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So yeah so that's the main flare treatment and I think the
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suggestion that was really helpful that the dermatologist
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was talking about that I learned from was saying that she
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does like a flare treatment visit to put out the fire and
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then she has them come back in about two to three weeks to
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assess how they're doing and to talk further about that kind
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of maintenance treatment and making sure that that's kind of
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all working for them. So I want to talk about emollients for
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a second. People have a lot of questions about that. So again
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it's something that's really thick hypoallergenic fragrance
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and dye free. White petroleum basically no one has any
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allergies to. And so that's also known as Vaseline is one
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of the brand names. I'm trying not to be partial to
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any brands here. Just an FYI people really love aquaphor
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and it's a really awesome type of treatment but it has
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white petroleum and it also has lanolin in it. And so if
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somebody is using that and they're having reactions or it's
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not working or the eczema is getting worse some people can
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have a reaction to lanolin. Usurins and CeraVe and
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Vanycream these can all be good options too but you
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want to look at ingredients because there's different lines
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for different types. Usurin I feel like tends to be the
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more bland one. CeraVe just has so many different types
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of lines within that brand and so it's important to kind
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of think about that. I didn't get any clear suggestions
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because it was a CEU and so it wasn't really recommended to
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do any brand names and so I was kind of reading between
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the lines there. Vanycream I've been familiar with. Again
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this is really not cheap stuff. So something to think
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about with your patients but white petroleum is pretty
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pretty cheap. And then things to avoid calendula is a
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really important popular ingredient right now but this
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can be really allergenic for some people. So somebody
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consider avoiding. Also it can come in things that have
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fragrance in them. Olive oil apparently can increase
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staph and so is not recommended. Coconut oil again
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is another kind of like trendy thing but maybe just
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is the preference of your patient. But that's okay to
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use coconut oil but you want to use the quote beauty
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kind and not necessarily like the cooking kind.
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Apparently there are differences. And if patients
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want to be using an oil like olive oil the
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recommendation that I got from the dermatologist was
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sunflower extract oil but I cannot imagine how expensive
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that must be especially if you're using large bottles
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of it all over your child. So something to think
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about there. So bleach bath. So someone told me about
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this I was familiar with it but I just felt like
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I didn't have good guidance on it and so I
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didn't feel like I could recommend it to patients.
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But basically what this is is a bath one to
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two times per week. There's some variable evidence
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there's evidence that it's helpful there's evidence
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that it's not necessarily more effective than
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regular bathing. Nothing has come back harmful as
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I understand but it's actually recommended by the
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IDSA the Infectious Disease Society of America for
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recurrent MRSA infections. I didn't I couldn't find
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anything that recommended recommended it specifically
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for eczema but the thought is that it's
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anti-inflammatory and it can kill the germs
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which is like one of the pillars of eczema
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treatment. Right. And so if you're going to
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fill a tub and again they're different tub sizes
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right but approximately it's a half tub full of
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with a quarter cup of bleach or if it's a baby
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bath it's just one teaspoon a very very tiny
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amount. And the way that the dermatologist
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referred to it as which I loved was a swimming
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pool bath which I totally will use in my
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clinical practice. And I feel conflicted about
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this but I think because it just it's odd to
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me to use bleach but I think that seeing the
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number of patients that I've seen come in with
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really severe eczema just really suffering I
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think I am I am going to add this to my
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repertoire. What wraps is another thing which I
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just felt like really does that actually work
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but apparently it does. And it doesn't have to
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be anything fancy but basically what it
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involves is just the the cheapest version is
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to wrap to dress your child or dress the
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patient in damp cotton pajamas that have
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been like put in water like wrung out or
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just damp now and then they just go to bed
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wearing that right. Which sounds super strange
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but apparently is really effective. And then
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another suggestion is actually a mom mom's
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group hack is that cotton pajamas depending on
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the season right. But you could cover them
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with a pair of fleece pajamas who didn't get
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like the bed all wet or you could cover it
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like a sweatshirt or something like that. But
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that's the that's the moral of the story
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with what wraps there are a ton of like
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fancy types of things that people can buy
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like I don't know. I don't even know the
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brand names but but yeah I don't think you
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have to get fancy about it. I think you can
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just kind of wrap it up. So topical steroids
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I feel like is such a huge the main question
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right. And so topical steroids you can use
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these up to about 15 days per month. There
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are different formulations. There's creams
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oils ointments and oils and ointments tend
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to be the preference. But again I always
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defer back to cost because just from the
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patient population that I work with but
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also like who doesn't who wants to spend
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like a ton of money on this right. I don't
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know. It just it seems like it will add
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up. So oils apparently there is like a
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fluosanide oil. Anyway I haven't ordered
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that myself yet but I'm going to. Ointments
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and then also you can wrap those up and
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so with eczema you can get those like
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lichenified plaques where they're really
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really thickened from all the repeated
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excoriation and it can be hard to
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penetrate that. And so a suggestion is
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that you can put the topical steroid on
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and then just wrap their arm or wherever
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the wherever it is with like some sort
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of plastic wrap for like 15 minutes or
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something like that just to help it
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penetrate a little bit better. The thought
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behind the 15 days is that if it's more
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than that they might need a different
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maintenance plan than what you kind of
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have in front of you. So they might
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need a dermatology referral if you're
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getting a little bit fancy here or
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they're getting a little bit more
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complicated and more on the moderate
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to severe side versus a mild eczema.
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And then another thing to think about
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is like do we have the right diagnosis
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here. Do they have a bacterial
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infection on top of it. And so signs
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of that would be things like increased
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redness drainage. You could consider
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which is a topical antibiotic treatment
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for that. And then another another thing
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that the dermatologist sees a lot is
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that there's post inflammatory hyper or
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hypo pigmentation that people can tend
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to think that this is still eczema.
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But the kind of rule of thumb there
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is that it really should feel like
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something like it should feel if it
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feels like sandpaper then you can go
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ahead and apply it. But if it feels
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just like normal skin that's a
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different color then don't use the
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steroids anymore. And that's really
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00:16:03.510 --> 00:16:04.510
important I think with different
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there's there's many different types
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of skin tones and different
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presentations that you'll see eczema
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in and it really comes down to itch
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and then the feel as well. There's
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also a table of steroid potencies.
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00:16:17.190 --> 00:16:19.310
And so what you're instead of giving
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00:16:19.310 --> 00:16:20.970
you specific names of the different
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00:16:20.970 --> 00:16:21.970
steroids to use I'll give you
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the classes that are recommended. And
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so class one is the most potent and
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which is also in the cheat sheet.
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And so hands and feet can use
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like the most potent topical steroid.
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Class four tends to be for like
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the rest of the rest of the body.
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And I have the note here 80
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kilograms 80 grams because
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depending on the tubes that you're
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used to sending to the pharmacy 15
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grams is not enough to use on
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somebody's body. So that was the
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recommendation of the dermatologist
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to use at least 80 grams a large
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enough tube so that they have
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enough supply. And then class six
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which is close to the bottom.
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Seven is the least potent.
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Those are the for the flexural
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areas and for the face. And you
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00:17:06.410 --> 00:17:08.849
can use a smaller tube gram
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amount for the tube for that.
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So about 30 grams.
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So food allergy. So this is
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another big question of like
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00:17:15.190 --> 00:17:16.230
should I test them for food
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allergies like do they have a
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00:17:17.650 --> 00:17:18.470
food allergies that what's
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00:17:18.470 --> 00:17:20.670
causing it. So basically no.
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But you want to consider food
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allergy in kids under five with
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00:17:24.349 --> 00:17:27.250
moderate to severe eczema if one
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00:17:27.250 --> 00:17:29.310
or more applies. So they have
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persistent symptoms despite
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00:17:31.210 --> 00:17:32.730
optimized maintenance and flare
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treatment. And the reason I say
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no is because most of the time
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00:17:35.970 --> 00:17:37.650
they're not optimized in their
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maintenance and flare treatment.
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And when you send them to
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dermatology they get them to a
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point where it's under control.
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So reliable history of food
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reaction. So they need at least
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one of those.
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Or yes. So actually I think
347
00:17:53.530 --> 00:17:54.270
those are the only two I
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thought there were three but
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00:17:54.970 --> 00:17:56.250
there's only two there. But
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yeah if they've if they
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00:17:57.130 --> 00:17:58.570
visibly had a food reaction
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if they have other things I
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00:18:00.090 --> 00:18:01.150
vote consistent with the milk
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allergy or or other kind of
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00:18:02.870 --> 00:18:03.710
allergy where they have blood
356
00:18:03.710 --> 00:18:04.730
in their stool or something
357
00:18:04.730 --> 00:18:06.310
like that they can be evaluated
358
00:18:06.310 --> 00:18:08.190
for milk eggs peanut wheat
359
00:18:08.190 --> 00:18:10.130
and soy allergies. However
360
00:18:10.130 --> 00:18:11.650
definitely send them to Derm
361
00:18:11.650 --> 00:18:13.130
first because Derm is going to
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00:18:13.130 --> 00:18:14.030
make sure that they're
363
00:18:14.030 --> 00:18:15.870
optimized in their eczema
364
00:18:15.870 --> 00:18:16.890
treatment because if they
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00:18:16.890 --> 00:18:17.750
undergo all that testing
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00:18:17.750 --> 00:18:19.250
that's just a lot of a lot
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00:18:19.250 --> 00:18:20.390
of extra burden for the
368
00:18:20.390 --> 00:18:23.030
families to test for that
369
00:18:23.030 --> 00:18:24.210
and then to try to evaluate
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00:18:24.210 --> 00:18:25.590
them and all that kind of
371
00:18:25.590 --> 00:18:26.590
stuff especially breastfeeding
372
00:18:26.590 --> 00:18:27.570
moms that are deciding
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00:18:27.570 --> 00:18:28.950
whether or not to eliminate
374
00:18:28.950 --> 00:18:30.010
foods from their diet or
375
00:18:30.010 --> 00:18:31.210
change formulas or things
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00:18:31.210 --> 00:18:31.990
like that. So definitely
377
00:18:31.990 --> 00:18:33.070
send them to Dermatology
378
00:18:33.070 --> 00:18:33.570
first.
379
00:18:34.870 --> 00:18:36.010
So that's it for this
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00:18:36.010 --> 00:18:37.870
presentation. So definitely
381
00:18:37.870 --> 00:18:39.130
download the cheat down
382
00:18:39.130 --> 00:18:40.430
below this video if you
383
00:18:40.430 --> 00:18:41.930
haven't already or head
384
00:18:41.930 --> 00:18:43.470
over to realworldnp.com
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00:18:43.470 --> 00:18:44.570
slash guide to grab the
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00:18:44.570 --> 00:18:45.290
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bonus content that I just
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00:18:51.350 --> 00:18:52.650
don't share anywhere else
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00:18:52.650 --> 00:18:54.190
patient stories insights
394
00:18:54.190 --> 00:18:56.050
extra videos things like
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00:18:56.050 --> 00:18:57.490
that. So thanks so much
396
00:18:57.490 --> 00:18:58.610
for hanging out. Definitely
397
00:18:58.610 --> 00:18:59.210
let me know if you have
398
00:18:59.210 --> 00:19:00.290
any questions and I'll
399
00:19:00.290 --> 00:19:00.910
see you soon.
400
00:19:09.280 --> 00:19:10.480
That's our episode for
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00:19:10.480 --> 00:19:12.120
today. Thank you so much
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so much again for
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00:19:42.080 --> 00:19:43.360
listening. Take care and
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talk soon.
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