Management of difficult-to-treat atopic dermatitis.

Atopic dermatitis is a complex disorder caused by the interplay between multiple genetic and environmental factors. Particularly in patients with severe disease, the effect is not just an itchy rash but also the secondary effects on the psychological well-being of the patient and their carers, particularly disturbed sleep. The aim of this review is to provide health care professionals with a holistic approach to the management of difficult-to-treat atopic dermatitis, defined as atopic dermatitis seemingly unresponsive to simple moisturizers and mild potency (classes VI and VII) topical corticosteroids. The critical importance of education and advice is emphasized, as is the seminal role of secondary bacterial infection and polyclonal T-cell activation in causing acute flares in patients with severe, generalized disease. In atypical cases or those that do not respond to treatment, alternative diagnoses should be considered.