Atopic dermatitis medical therapy

Atopic dermatitis Microchapters
Home
Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Atopic dermatitis from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
X-ray
Echocardiography or Ultrasound
CT Scan
MRI
Other Imaging Findings
Other Diagnostic Studies
Treatment
Medical Therapy
Surgery
Primary Prevention
Secondary Prevention
Cost-Effectiveness of Therapy
Future or Investigational Therapies
Case Studies
Case #1
Atopic dermatitis medical therapy On the Web
Most recent articles
Most cited articles
Review articles
Programs
Powerpoint slides
Images
American Roentgen Ray Society Images of Atopic dermatitis medical therapy All Images X-rays Echo & Ultrasound CT Images MRI
Ongoing Trials at Clinical Trials.gov
US National Guidelines Clearinghouse
NICE Guidance
FDA on Atopic dermatitis medical therapy
CDC on Atopic dermatitis medical therapy
Atopic dermatitis medical therapy in the news
Blogs onAtopic dermatitis medical therapy
Directions to Hospitals Treating Atopic dermatitis
Risk calculators and risk factors forAtopic dermatitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shalinder Singh, M.B.B.S.[2]

Overview

The mainstay of treatment for atopic dermatitis depends upon the severity of the disease. The treatment involves a combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation. Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales including SCORAD index, the eczema area and severity index (EASI) and the patient-oriented eczema measure (POEM).

Conservative Therapy

Elimination of exacerbating factors	Maintaining skin hydration	Controlling pruritus
Avoid triggers such as low humidity, overheating of skin Treat stress and anxiety Avoid exposure to solvents and detergents Treat skin infections such as Staphylococcus aureus and herpes simplex.	Emollients and moisturizers Thick creams, ointments (eg, petroleum jelly) with low/zero water content Apply emollients immediately after lukewarm baths twice daily Bathing practices Warm soaking baths or showers using mild or soap-free cleansers	Tepid baths Wet dressings (wet wraps) Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor

Medical Therapy

• Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales including SCORAD index, the eczema area and severity index (EASI) and the patient-oriented eczema measure (POEM) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.

Atopic dermatitis

• 1. Mild atopic dermatitis:
  • 1.1 Topical corticosteroids and emollients - mainstay therapy
    • 1.1.1 Adult
      • Preferred regimen (1): Desonide 0.05% top. q12h-q24h for 14-28 days
      • Preferred regimen (2): Hydrocortisone 2.5% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): Fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
      • Alternative regimen (1): Tacrolimus 0.1% top. q12h (0.03% for adults who do not tolerate the higher dose)
      • Alternative regimen (2): Pimecrolimus 1% top. q12h
      • Alternative regimen (3) Crisaborole 2% top.
    • 1.1.2 Pediatric
      • Preferred regimen (1): Desonide 0.05% top. q12h-q24h for 14-28 days
      • Preferred regimen (2): Hydrocortisone 2.5% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): Fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
      • Alternative regimen (1): Tacrolimus 0.03% top. q12h (Children (>2years)
      • Alternative regimen (2): Pimecrolimus 1% top. q12h
      • Alternative regimen (3): Crisaborole 2% top.
• 2 Moderate atopic dermatitis
  • 2.1 Topical corticosteroids and emollients - mainstay therapy
    • 2.1.1 Adult
      • Preferred regimen (1): Fluocinolone 0.025%. q12h-q24h for 14-28 days
      • Preferred regimen (2): Triamcinolone 0.1% top. q12h-q24h for 14-28 days
      • Preferred regimen (3): Fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1): Tacrolimus 0.1% top. q12h (0.03% for adults who do not tolerate the higher dose)
      • Alternative regimen (2): Pimecrolimus 1% top. q12h
      • Alternative regimen (3): crisaborole 2% top.
    • 2.1.2 Pediatric
      • Preferred regimen (1): Fluocinolone 0.025%. q12h-q24h for 14 days
      • Preferred regimen (2): Triamcinolone 0.1% top. q12h-q24h for 14 days
      • Preferred regimen (3): Fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1): Tacrolimus 0.03% top. q12h (Children (>2years)
      • Alternative regimen (2): Pimecrolimus 1% top. q12h
      • Alternative regimen (3): crisaborole 2% top.
• 3. Severe atopic dermatitis
  • 3.1 Phototherapy or systemic immunosuppressant treatment - mainstay therapy
    • 3.1.1 Adult
      • Preferred regimen (1): Phototherapy (Ultraviolet light therapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
      • Preferred regimen (2): Cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
      • Alternative regimen (1): Methotrexate PO
      • Alternative regimen (2): Azathioprine PO
      • Alternative regimen (3): Mycophenolate mofetil PO
      • Alternative regimen (4): Dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
    • 3.1.2 Pediatric
      • Preferred regimen (1): Phototherapy (Ultraviolet light therapy) with PUVA ( psoralens plus ultraviolet A radiation), 3 times a week(older children > 6 years)
      • Alternative regimen (1): Cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor blood pressure and serum creatinine every 2 weeks for three months, f/b every month)
      • Alternative regimen (2): Azathioprine PO
      • Alternative regimen (3): Mycophenolate mofetil PO
      • Alternative regimen (4): Dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
• 4. Severe refractory atopic dermatitis
  • 4.1 Adult
    • Preferred regimen (1): Intensive topical therapy
      • Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face.
      • Wet wrap therapy: Desoximetasone 0.25% top. then occluded with wet wraps q12h
    • Alternative regimen (1): Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
    • Alternative regimen (2): Cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
    • Alternative regimen (3): Prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
    • Alternative regimen (4): Methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
    • Alternative regimen (5): Azathioprine 2 to 3 mg/kg
    • Alternative regimen (6): Mycophenolate mofetil 1 to 2 g/day
    • Alternative regimen (7): Mycophenolic acid 720 to 1440 mg/day
    • Alternative regimen (8): Dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
  • 4.2 Pediatric
    • Preferred regimen (1): Intensive topical therapy
      • Wet wrap therapy: Desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
    • Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
    • Alternative regimen (2): Cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
    • Alternative regimen (3): Methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
    • Alternative regimen (4): Methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month

Other Drugs for atopic dermatitis:

• Interferon-γ sub-q o.d. for 12 weeks
• Anti-CD20 therapy
  • Rituximab
• Anti-IgE
  • Omalizumab
• Anti-TNFα therapy
  • Infliximab
• Anti-IL-6 receptor therapy
  • Tocilizumab

Adjuvant treatment:

• Primrose oil
• Omega-3
• Probiotics
• Chinese herbal medicines
• Oral vitamin D

Management of Infections:

• Bacterial infections: (most common bacteria - Staphylococcus aureus)
  • Clinically infected skin:
    • Mupirocin 2% top. BID for one to two weeks
    • More extensive infection: Oral antibiotic therapy with cephalosporins or penicillinase-resistant penicillins for two weeks.
  • Clinically uninfected skin:
    • Liquid chlorine bleach-  0.5 cup or 120 ml of 6% bleach in a full bathtub [40 gallons or 150 L] of lukewarm water
• Viral infections:
  • Herpes simplex virus:
    • Acyclovir 200 or 400 mg PO five times daily
    • Famciclovir 750 mg BID for one day or 1500 mg as a single dose
  • Molluscum contagiosum :
    • Cryotherapy, curettage, cantharidin, and podophyllotoxin as first-line therapeutic options.
• Fungal infections:
  • Dermatophyte infections - topical or oral antifungals

Controlling pruritus:

• Preferred regimen:
  • Sedatives: Diphenhydramine, hydroxyzine, and cyproheptadine
  • Nonsedatives: Fexofenadine, cetirizine or loratadine
• Alternative regimen:
  • Topical doxepin
  • Topical calcineurin inhibitors
    •  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%