Atopic Dermatitis Treatment

Goals of Treatment

The overall goal of treatment of atopic dermatitis (AD) should be to achieve a state in which symptoms are absent or mild without causing disturbance in activities of daily living and in which drug therapy is not required.
If this is not reached, the goal should be to maintain a state in which symptoms are mild and to decrease the rate of acute flares/disease exacerbations.

Treatment Interventions

Drug therapy (topical, oral, injectable)
Basic treatment of a disturbed skin barrier, or “skin care regimen” (eg, emollients)
Control of pruritus using oral antihistamines

Current Treatment Options^1–4

Topical emollients
Topical anti-inflammatory agents (topical corticosteroids and/or topical calcineurin inhibitors)
Oral antihistamines (sedating and non-sedating)
Crisaborole (phosphodiesterase 4 [PDE-4] inhibitor)
Phototherapy (narrowband ultraviolet B or ultraviolet A)
Oral corticosteroids
Other systemic immune suppressants (eg, cyclosporine, methotrexate, and azathioprine)
Oral antibiotics
Calcineurin inhibitors (tacrolimus, pimecrolimus)
Dupilumab
Adjuvant therapies and approaches (eg, wet wraps, soak-and-smear, and diluted bleach baths)
Other treatments (eg, omalizumab, rituximab, rapamycin, intravenous immunoglobulin, gamma interferon [these are not yet FDA-approved for AD])

Please consult product labels for prescribing information on individual therapies. Considerations for Treatment^4–6

Most patients with mild AD can expect clinical improvement and disease control with use of emollients, conventional topical therapies, and environmental and/or occupational modifications.(Figure 1)
These interventions may not be sufficient for patients with moderate-to-severe or difficult-to-control disease.
Phototherapy and/or systemic therapies for AD
- Phototherapy is recommended for both acute and chronic disease.
- Systemic therapies are recommended for use after failure to achieve disease control with use of the above measures.

Experimental agents
- JAK inhibitors: tofacitinib,⁷ baricitinib,⁸ and upadacitinib⁹ have shown efficacy in clinical trials.^7–9 Topical JAK inhibitors include delgocitinib and ruxolitinib.
- Anti–interleukin (IL)-31 receptor humanized antibody: nemolizumab has exhibited promise in phase 2 trials.¹⁰
- Anti–IL-13 monoclonal antibody: lebrikizumab is undergoing studies and can potentially provide additional benefit when used with topical corticosteroids as compared with topical corticosteroids alone.¹¹
- Anti–IL-22 monoclonal antibody: fezakinumab, which blocks the IL-22 receptor, is a new agent with promise.¹²

References

Wang D, Beck LA. Immunologic targets in atopic dermatitis and emerging therapies: an update. Am J Clin Dermatol. 2016;17:425-443.
Roekevisch E, et al. Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: a systematic review. J Allergy Clin Immunol. 2014;133:429-438.
Mohan GC, et al. Comparison of dermatology and allergy guidelines for atopic dermatitis management. JAMA Dermatol. 2015;151:1009-1013.
Wollenberg A, et al. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients. J Eur Acad Dermarol Venereol. 2016;30:729-747.
Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71:327-49.
Saeki H, et al. Clinical practice guidelines for the management of atopic dermatitis 2016. J Dermatol. 2016;43:1117-1145.
Bissonnette R, et al. Topical tofacitinib for atopic dermatitis: a phase IIa randomized trial. Br J Dermatol. 2016;175:902-911.
Guttman-Yassky E, et al. Baricitinib in adult patients with moderate-to-severe atopic dermatitis: a phase 2 parallel, double-blinded, randomized placebo-controlled multiple-dose study. J Am Acad Dermatol. 2019;80:913-921.e9.
Guttman-Yassky E, et al. Upadacitinib in adults with moderate to severe atopic dermatitis: 16-week results from a randomized, placebo-controlled trial. J Allergy Clin. 2020;145:877-884.
Ruzicka T, et al. Anti-interleukin-31 receptor A antibody for atopic dermatitis. N Engl J Med. 2017;376:826-835.
Simpson EL, et al. Efficacy and safety of lebrikizumab (an anti-IL-13 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by topical corticosteroids: a randomized, placebo-controlled phase II trial (TREBLE). J Am Acad Dermatol. 2018;78:863-871.e11.
Guttman-Yassky E, et al. Efficacy and safety of fezakinumab (an IL-22 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by conventional treatments: a randomized, double-blind, phase 2a trial. J Am Acad Dermatol. 2018;78:872-881.e6.