What are the treatment options for chronic atopic dermatitis (eczema)?

From the Guidelines

Chronic eczema treatment should start with a gentle skincare routine and topical corticosteroids, with consideration of phototherapy or systemic therapies like dupilumab for severe cases, as recommended by the most recent guidelines 1.

Treatment Approach

The treatment of chronic eczema requires a multifaceted approach that includes:

• Daily skincare with fragrance-free moisturizers like CeraVe, Vanicream, or Eucerin applied multiple times daily
• Topical corticosteroids such as hydrocortisone 1% for mild cases or triamcinolone 0.1% for moderate cases, applied thinly to affected areas twice daily for 1-2 weeks
• Non-steroid alternatives like tacrolimus (Protopic) or pimecrolimus (Elidel) for sensitive areas
• Identification and avoidance of triggers such as harsh soaps, certain fabrics, stress, and allergens
• Short, lukewarm showers using mild cleansers, and patting skin dry rather than rubbing
• Wearing loose cotton clothing and keeping fingernails short to minimize damage from scratching

Systemic Therapies

For severe cases of chronic eczema, systemic therapies may be considered, including:

• Dupilumab injections, which have been shown to be effective in reducing inflammation and improving symptoms 1
• Phototherapy, such as narrowband ultraviolet B (UVB) phototherapy, which can be effective in reducing symptoms and improving quality of life 1
• Other systemic therapies like upadacitinib, abrocitinib, and baricitinib, which may be considered for patients who have failed other treatments 1

Importance of Shared Decision-Making

The decision to initiate systemic 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.

Key Considerations

• Consistent daily management is essential for long-term control of chronic eczema
• Patients should be monitored regularly to assess the effectiveness of treatment and adjust the treatment plan as needed
• The potential risks and benefits of each treatment option should be carefully considered, and patients should be educated on how to use topical and systemic therapies safely and effectively 1.

From the FDA Drug Label

ELIDEL ® (pimecrolimus) Cream 1% is indicated as second-line therapy for the short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older, who have failed to respond adequately to other topical prescription treatments, or when those treatments are not advisable. 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.

Treatment Options for Chronic Eczema:

• Pimecrolimus (TOP): can be used as second-line therapy for short-term and non-continuous chronic treatment of mild to moderate atopic dermatitis in non-immunocompromised adults and children 2 years of age and older.
• Dupilumab (SQ): can be used for the treatment of adult and pediatric patients aged 6 months and older with moderate-to-severe atopic dermatitis whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. Key Considerations:
• Pimecrolimus is for mild to moderate atopic dermatitis, while dupilumab is for moderate-to-severe atopic dermatitis.
• Pimecrolimus is a topical cream, while dupilumab is administered by subcutaneous injection. 2 3

From the Research

Treatment Options for Chronic Eczema

• Topical corticosteroids (TCS) are effective in treating chronic eczema, with group 5 TCS being among the most effective in maintaining AD control 4
• Topical calcineurin inhibitors, such as pimecrolimus and tacrolimus, are also effective in improving and maintaining multiple AD outcomes 4, 5
• Proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas can reduce the time to the next eczematous flare 6
• Systemic therapies, such as cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil, are available for the treatment of refractory AD, but their use should be based on efficacy and safety readouts from well-designed, long-term trials 7, 8
• Dupilumab is a safe and efficacious injectable therapy in elderly patients with chronic eczema 8

Management Strategies

• Identifying and avoiding allergens and irritants, ensuring skin moisturization, and graded use of topical corticosteroids and/or calcineurin inhibitors are important management strategies for chronic eczema 7
• Proper use of moisturizer is crucial in all patients with AD, especially in the elderly population 8
• Wet wrap therapy, anti-histamines, and vitamin D supplementation can be considered as adjunctive treatment options 6
• Local antiseptic measures, such as bleach baths, and topical antimicrobial therapies can be considered in patients with high bacterial colonization 6

Considerations for Specific Populations

• In elderly patients, topical corticosteroids should be used with caution due to the increased risk of adverse events, and systemic corticosteroids should be avoided due to questionable efficacy and increased adverse events 8
• Topical calcineurin inhibitors and crisaborole are similarly efficacious with an excellent safety profile in elderly patients 8