Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects.

We sought to systematically synthesize the benefits and harms of AD prescription topical treatments.

For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups—group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s).

The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes—among the best for 2; high-dose tacrolimus (0.1%) improved 5—among the best for 2; low-dose tacrolimus (0.03%) improved 5—among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6—among the best for 3; group 4 TCS and delgocitinib improved 4—among the best for 2; ruxolitinib improved 4—among the best for 1; group 1 TCS improved 3—among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus.

For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.