The American Academy of Dermatology (AAD) issued updated clinical recommendations advising doctors to re-evaluate the diagnosis of adult patients whose atopic dermatitis (eczema) remains uncontrolled despite following standard treatment protocols. The new guidance stresses that persistent symptoms should trigger an investigation into other possible conditions—such as allergic contact dermatitis, infections, psoriasis, or cutaneous T-cell lymphoma—before increasing medication strength.
This advice follows a shortage of direct research on diagnostic approaches for adults whose eczema does not improve with conventional care. A specialized group applied the GRADE methodology and reviewed available studies in 2024 and 2025, resulting in a Good Practice Statement (GPS) based on indirect evidence and expert opinions. The core message is that clinicians should first confirm whether patients have strictly followed all recommended treatments before concluding that therapy has failed.
Testing should be customized based on each patient’s symptoms rather than following a fixed set of procedures. While the guidelines do not prescribe a universal diagnostic path, they identify situations where further evaluation is particularly important:
- Patch testing when allergic contact dermatitis is a possibility, especially in adults who develop eczema later in life, cases with unusual rash locations (hands, face, eyelids), or chronic flare-ups that worsen despite standard treatments.
- Skin biopsies when the presentation suggests other inflammatory, autoimmune, or cancerous skin disorders, such as pityriasis rubra pilaris, bullous pemphigoid, or cutaneous T-cell lymphoma (CTCL).
- Microscopic skin scrapings and cultures to exclude infections like scabies or fungal infections, particularly if the rash pattern differs from typical atopic dermatitis.
Before requesting any tests, doctors must ensure patients have received and adhered to optimized treatment. Factors like limited access to care, complex treatment regimens, or patient fatigue can mimic resistance to therapy. The guidelines also clarify that there is no one-size-fits-all definition of treatment failure, as different medications require varying response periods.
When the diagnosis remains uncertain or serious conditions are suspected, the guidelines recommend consulting a dermatology specialist. Additional tests, such as photopatch testing for rashes triggered by sunlight or blood tests for widespread disease, may then be necessary.
The recommendations were published in the Journal of the American Academy of Dermatology on August 27. The authors emphasized the need for further studies to develop standardized diagnostic tools, identify biomarkers that guide testing decisions, and assess how expanded evaluations affect patient results.
Current evidence on diagnosing treatment-resistant adult eczema is limited. The absence of direct research means existing advice relies on adapted findings and clinical judgment. This inconsistency suggests that real-world practices differ significantly, with some providers routinely ordering broader tests while others stick closely to standard eczema management protocols.
For patients and doctors, the guideline reinforces that persistent atopic dermatitis, even after proper treatment, should not be automatically labeled as untreatable. A thorough reassessment, shaped by the patient’s symptoms, may reveal underlying conditions explaining why the skin remains inflamed.
This marks the first time the AAD has issued specific guidance on this issue for adult patients. Previous recommendations focused primarily on pediatric cases, leaving a critical gap in care for older adults whose eczema behaves differently and often requires more specialized evaluation.