Practical Algorithm on Topical Treatment of Flaring Atopic Dermatitis (AD) With or Without Secondary Infection
June 2025 | Volume 24 | Issue 6 | 621 | Copyright © June 2025
Published online May 30, 2025
Lawrence A Schachner MD FAAD FAAPa, Adelaide A Hebert MD FAADb, Robert Sidbury MD FAAD FAAPc, Anneke Andriessen PhDd, Vanja Adzovic PharmDe, Mercedes E Gonzalez MD FAADf, Elizabeth Swanson MDg, Shawn G. Kwatra MDh, E. James Song MDi, Dennis West PhDj, Peter Lio MD FAADk
aDermatology and Pediatrics, Pediatric Dermatology, University of Miami School of Medicine, Miami, FL
bDepartment of Dermatology and Pediatrics, McGovern Medical School, and Children's Memorial Hermann Hospital, Houston, TX
cDivision of Dermatology, Department of Pediatrics, Seattle Children's Hospital; University of Washington School of Medicine, Seattle, WA
dRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands
eBlue Quill Communications, Toronto, Canada
fPediatric Skin Research, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine Miami, FL
gAda West Dermatology, St. Luke's Children’s Hospital Meridian, ID
hDermatology, University of Maryland School of Medicine and UM Medical Center, Baltimore City, MD
iFrontier Dermatology, Mill Creek, WA
jDermatology, Northwestern University Feinberg School of Medicine, Chicago, IL
kDermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
Abstract
Acute exacerbations or flares are a key characteristic of atopic dermatitis (AD), often associated with sleep deprivation, as well as experiences of stigmatization, social withdrawal, anxiety, and depression. Local skin colonization with Staphylococcus aureus (SA) is a key contributor to AD, particularly to AD flares. Treating SA-driven active AD, especially in cases where skin that is secondarily infected complicates management, calls for a carefully balanced approach that serves to calm AD activity and clear local infection and SA related colonization. The methodological approach included a systematic literature review to inform an expert panel before a face-to-face meeting to develop a practice-based algorithm for managing AD flares with or without secondary infection. A panel of nine experts in dermatology, including both Board-certified dermatologists and pediatric dermatologists, engaged in a discussion followed by an online review to refine the algorithm and to provide clear guidance on the topical treatment of flaring AD with or without AD skin that is secondarily infected. The algorithmic recommendations emphasize a need for therapy that addresses both skin inflammation and local SA colonization and/or infection, underscoring the unmet need for multi-targeted topical therapies such as zabalafin hydrogel, a novel approach under current investigation for persons with active AD, including flaring and secondary infected AD. This novel practice-based algorithm aims to improve outcomes for all AD patients, especially those with frequent flares or secondary infections and highlights the importance of balancing efficacy with antibiotic stewardship.
Citation: Schachner LA, Hebert AA, Sidbury R, et al. Practical algorithm on topical treatment of flaring atopic dermatitis (AD) with or without secondary infection. J Drugs Dermatol. 2025;24(6):621-630. doi:10.36849/JDD.8967
INTRODUCTION
Atopic dermatitis (AD), a chronic, relapsing inflammatory skin condition that affects approximately 20% of children and up to 10% of adults, is characterized by xerosis, localized or diffuse erythematous scaly patches, and usually intense pruritus.1 AD is associated with sleep disruption for patients of all ages, decreased work productivity, depression, and anxiety, which all carry additional health and economic burdens for patients and those in their households.1,2 There is also a well-established association between AD and other morbidities. As such, AD development in an individual often marks the beginning of the "atopic march," a term used to describe the increased risk of developing one or more of the other diseases as part of atopy, including asthma, food allergy, and allergic rhinitis.3,4
AD is viewed as predisposing an individual to acute exacerbations and recurrent bacterial and viral skin infections.4 Unlike healthy individuals and those with certain other inflammatory skin conditions such as psoriasis, up to 90% of patients with AD are colonized with Staphylococcus aureus (SA).5 SA plays a significant role in AD, producing enterotoxins that disrupt the skin barrier, enhance type 2 inflammation, and contribute to AD exacerbations and infectious complications.5
