The key factors to determine therapies for patients are extent of disease, symptom severity, quality of life issues, patient desire for certain types of therapies, and access/affordability issues. With these in mind I try to work with the patient to come up with the simplest and safest means to tame their disease that is likely to work. If they don't achieve adequate control we discuss the risks/benefits of various means of increasing their therapy so they can ultimately achieve their goals.

AD is a chronic autoimmune skin condition that fluctuates due to multiple environmental triggers and stressors. I have all AD patients optimize OTC care with mild cleansers and emollients, and use topical steroid ointments or protopic as needed for flares. If needed, I will add opzelura cream for short-term treatment of flares in mild to moderate AD patients.
If not improving with moderate to severe AD, then I will consider systemics/bologics/oral JAKs.

An allergy eval if they are at moderate severity. Not often positive but if so, helps with management.
Oral antihistamine regardless to help control the itch. I try to limit oral steroids as much as possible. Sometimes use increase potency topical steroids, if insurance will cover then elidel or eucrisa. It's ridiculously hard here to get eucrisa approved.
Baseline hydration is always the most important. If they're not improving, we get a Derm referral

Atopic dermatitis is the itch that rashes so controlling the itch is critical. Too often patients do not consistently moisturize. Unfortunately, insurance companies will often not cover options other than steroids.

Yes flare ups are common. If it is severe I try a 5 day course of oral steroids before transitioning to a new topical

Atopic Dermatitis does not happen overnight, one of the chronic conditions that is being overlooked sometimes or being treated differently by dermatologists to satisfy the patient population. OTC or natural remedies like vaseline better control than traditional treatments like topical and anti-itch meds.

Atopic dermatitis considerations should discuss allergans, as well as asthma . Transitioning to newer products available should be done as soon as possible to prevent worsening, especially if there has not been any significant changes.

I would review frequency and severity of flare ups. If continues to flare despite topical CS/CI would discuss biologic therapy

An important thing to remember when treating most dermatologic conditions (but especially pediatric dermatoses like atopic eczema, where this impacts both patient and parent) is that our most frequently recommended treatments (ie, topicals) are time consuming and difficult to do. The fewer steps in the treatment protocol, the more likely they are to be followed.

Topical is preferred, but if the patient has been compliant and has not improved, certain families and patients may benefit from oral tx, perhaps during peak flare up times only. It is important to consider patient compliance, affordability and trigger modification.

Must use some agents even temporarily that help break the itch scratch cycle. Patients will not continue on meds as prescribed if they are itching - they will either abandon the meds or add to them on their own. Must balance out the drying effects of many meds including steroids with cocoa butter or the like to prevent drying which is essentially going to cause itching for a different reason. As the intensity of the condition progresses form mild to moderate, it becomes more useful to use the newer agents and may do so before adding to much of the oral realm. Strongly consider using medication from the inside out (orally) if there is a lot of itching as well. Patients do not red, swollen, or itchy - any persistence of these will make them anxious to jump ship and try alternative measures - even bad options.

After disease flares in mild-to-moderate AD, the key is to use the topical steroids regularly at BID dosing even past the point of improvement or clearance (reminding patients there's still inflammation beneath the surface they can't see), then gradually taper down over 1-2 more weeks. If the flares are frequent, then a maintenance qod dosing with a milder topical steroid or a rx. non-steroid topical agent may provide better long-term control.
For moderate AD patients, any of the newer topical agents can be tried, but I'd reserve the oral JAK inhibitors for only the most severe patients, given their multiple black box warnings. Dupixent is generally preferred by patients as the first systemic option (beyond oral antihistamines). And allergen immunotherapy remains an effective modulatory treatment for many allergic AD patients, although some patients may flare a bit during the initial build-up phase.

Stop itch scratch cycle

I always start with topical medications, usually, when used with a good emollient cream and done regularly, this will keep the symptoms at bay fairly well. If I feel that isn't working anymore I would refer them to dermatology for more systemic options. I also will have them take zyrtec to help with the itching

AD is often mild and well controlled with topical therapy such as topical steroids for flares and calcineurin inhibitors for maintenance therapy. If there is concomitant asthma that is poorly controlled, dupilumab is a very good option. Ruxolitinib topical cream is also very effective.

Topical steroids for flares. Good environmental review and control with possible cross coverage with allergy consultation. Good skin care, of course. Consider Protopic for daily regular, suppressive therapy.

As an atopic who suffered(s) from food and environmental allergies, eczema, hay fever, hives, and asthma, I recommend no fur/feathered pets, avoid allergens, and to either test and treat or promptly treat (if no kidney disease) for intestinal Ascaris/tapeworms with diatomaceous earth (food grade) in psyllium daily, working up from 1 teaspoon in an 8 oz. glass of water with 1 tablespoon psyllium; gradually increasing over 2 weeks to 1 tablespoon diatomaceous and 1 tablespoon psyllium for 30 days.
At St. John's in London we used wraps on top of a bland emollient base with weak additions of hydrocortisone. I prefer Aveeno cream and hydrocortisone ointment.

The biggest factor is control of disease as this affects quality of life. If the patient hasn't responded to topical steroids, oral antihistamines, and topical moisturizers, in 3 to 6 months, I would consider Eucrisa or Opzelura.

Main issue with atopic dermatitis is how it affects quality of life. Most patients have mild disease that can be managed with local treatment and avoidance of triggers. Side effects of oral drugs affects compliance so short course for severe flares can be done.

Many patients can be maintained on topical steroids, emollients, avoidance of allergens and irritants and other skin care/life style modifications. When that doesn't provide adequate control, transition to a calcineurin inhibitor or Eucrisa or Ozelura is reasonable. The goal is to maintain quality of life (suppression of itch, maintenance or sleep patterns etc.). If creams aren't doing it, the patient should consider systemic therapy, either a biologic or a JAK.

AD is a chronic autoimmune skin condition that fluctuates due to multiple environmental triggers and stressors. I have all AD patients optimize OTC care with mild cleansers and emollients, and use topical steroid ointments or protopic as needed for flares. If needed, I will add opzelura cream for short-term treatment of flares in mild to moderate AD patients.
If not improving with moderate to severe AD, then I will consider systemics/bologics/oral JAKs.

extent of diseases state, affected area, size of area. previous hx of tx. safety prefers topical vs oral for more severe wide spread cases

The effect on sleep/school/home life plays a major factor in my choices of treatment for these patients. Also their tolerance for topicals from a sensory standpoint has been a major consideration in my peds population. Most patients need a dual approach, i.e., antihistamines plus topicals and a plan for maintenance therapy.

The main objectives are to help with their type 2 inflammation

Atopic dermatitis is an inflammatory immune related skin disease manifested by pruritus The key factor is to control itch and stop inflammation

AD is a chronic condition that can wax and wane
I generally advise pts to consider maintenance therapy (topical non steroid options like the calcineurin inhibitors and Eucrisa ) and topical steroids and now opzelura for flares
Individual cases differ as to what else is needed (eg systemic antihistamines etc)
We also discuss lifestyle and environmental triggers

Always preferable to go with topical. Quality of life is a decising factor in advancing tx