What are the treatments for severe atopic dermatitis (eczema)?

From the Guidelines

Severe eczema treatment should prioritize a multi-faceted approach combining topical therapies, systemic medications, and lifestyle modifications, with a focus on reducing inflammation, restoring skin barrier function, and modulating the overactive immune response, as recommended by the most recent guidelines 1.

Treatment Options

• Topical treatments: high-potency corticosteroids like clobetasol propionate 0.05% applied twice daily for 1-2 weeks during flares, and calcineurin inhibitors such as tacrolimus 0.1% ointment or pimecrolimus 1% cream for sensitive areas like the face.
• Systemic therapy: oral immunosuppressants including cyclosporine (2.5-5 mg/kg/day), methotrexate (7.5-25 mg weekly), or azathioprine (1-3 mg/kg/day) for severe cases, and newer biologic medications like dupilumab (300 mg subcutaneous injection every two weeks) for moderate-to-severe eczema.
• Phototherapy: narrowband UVB light 2-3 times weekly for 6-12 weeks can also be effective.
• Lifestyle modifications: daily skin care with gentle fragrance-free cleansers, regular moisturizing with thick emollients like petroleum jelly or ceramide-containing creams, and avoiding known triggers.

Personalized Treatment

Treatment should be personalized based on severity, affected areas, and patient response, with regular monitoring for potential side effects, as emphasized by the guidelines 1. The decision to initiate advanced therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of eczema, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1.

Evidence-Based Recommendations

The American Academy of Dermatology guidelines suggest that emollients and prescription topical therapies are sufficient to achieve eczema control for most people, but people with more severe or widespread eczema may consider phototherapy or systemic therapies to improve disease control and quality of life 1. The guidelines highlight new evidence that supports strong recommendations for the use of biologics and Janus kinase inhibitors, such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib, and conditional recommendations for phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate 1.

From the FDA Drug Label

DUPIXENT is indicated for the treatment of adult and pediatric patients aged 6 months and older with moderate-to-severe atopic dermatitis (AD) whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. DUPIXENT can be used with or without topical corticosteroids.

Treatments for severe eczema include dupilumab (DUPIXENT), which is a prescription medicine used to treat adults and children 6 months of age and older with moderate-to-severe eczema (atopic dermatitis or AD) that is not well controlled with prescription therapies used on the skin (topical), or who cannot use topical therapies.

• Key points:
  • DUPIXENT can be used with or without topical corticosteroids.
  • It is intended for use under the guidance of a healthcare provider.
  • Provide proper training to patients and/or caregivers on the preparation and administration of DUPIXENT prior to use. 2 2 2

From the Research

Treatments for Severe Eczema

• Topical corticosteroids are a common treatment for eczema, with potent and moderate topical corticosteroids being more effective than mild topical corticosteroids in treating moderate or severe eczema 3
• The use of topical corticosteroids once daily is probably as effective as twice daily application in treating eczema flare-ups 3
• Topical corticosteroids weekend (proactive) therapy is probably better than no topical corticosteroids/reactive use to prevent eczema relapse (flare-ups) 3
• Janus kinase inhibitors, such as ruxolitinib, and tacrolimus 0.1% are among the most effective topical anti-inflammatory treatments for eczema 4
• Topical calcineurin inhibitors, such as tacrolimus, can improve disease severity, especially on thin or intertriginous skin regions most vulnerable to adverse events with topical corticosteroid treatment 5

Comparison of Treatments

• Tacrolimus had statistically significant improvement in disease severity compared with weak topical corticosteroids in 4 of the 5 studies that compared tacrolimus with weak topical corticosteroids 5
• The data suggest greater treatment efficacy of tacrolimus over weak topical corticosteroids, and inferior efficacy of pimecrolimus compared with both tacrolimus and weak topical corticosteroids 5
• Topical calcineurin inhibitors are useful for sensitive sites, and their use may help overcome adherence issues due to patient bias against topical corticosteroids 6

Treatment Recommendations

• Topical corticosteroids should be used once daily rather than twice daily 6
• Systemic therapies, such as cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate, may be considered for severe disease 7
• Good patient education and aggressive use of topical therapies, including the 'get control then keep control' regimen, are important for managing eczema 6