What is the management plan for treating widespread severe atopic dermatitis (eczema)?

From the Guidelines

A comprehensive management plan for widespread severe atopic dermatitis (eczema) should include multiple approaches, starting with topical corticosteroids and moisturizers, and considering systemic treatments such as dupilumab, oral immunosuppressants, or methotrexate for severe cases, as recommended by the American Academy of Dermatology guidelines 1.

Key Components of Management Plan

• Topical corticosteroids like triamcinolone 0.1% or fluocinonide 0.05% for affected areas twice daily for 1-2 weeks during flares, then taper to maintenance use
• Daily moisturizer like CeraVe or Vanicream applied liberally after bathing to maintain skin barrier function
• Systemic treatments such as:
  • Dupilumab (300mg subcutaneous injection every two weeks after a 600mg loading dose) 1
  • Oral immunosuppressants like cyclosporine (3-5mg/kg/day in divided doses) or methotrexate (15-25mg weekly) 1
• Trigger avoidance: identify and eliminate contact allergens, use fragrance-free products, wear loose cotton clothing, and maintain optimal humidity levels at home
• Short lukewarm showers with gentle cleansers to prevent further irritation
• Antihistamines like hydroxyzine (25mg at bedtime) to manage nighttime itching
• Wet wrap therapy for acute flares by applying medication, moisturizer, then damp bandages for 2-3 hours

Considerations for Systemic Treatments

• The decision to initiate systemic treatments should be made using shared decision-making between patients and clinicians, taking into account the severity of AD, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1
• The American Academy of Dermatology guidelines recommend dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib for adults with moderate to severe AD, with strong recommendations for their use 1
• Methotrexate and cyclosporine are conditionally recommended for adults with moderate to severe AD, with low certainty of evidence 1

Importance of Patient Education and Support

• Time for explanation and education is essential to ensure patient understanding and adherence to treatment plans 1
• Patients with atopic eczema may benefit from cognitive behavioral techniques such as relaxation therapy or self-hypnosis, and access to a clinical psychologist is recommended 1
• The National Eczema Society can provide valuable support and resources for patients with eczema 1

From the FDA Drug Label

The patient or care giver should apply a thin layer of ELIDEL (pimecrolimus) Cream 1% to the affected skin twice daily. The patient or caregiver should stop using when signs and symptoms (e.g., itch, rash and redness) resolve and should be instructed on what actions to take if symptoms recur. If signs and symptoms persist beyond 6 weeks, patients should be re-examined by their health care provider to confirm the diagnosis of atopic dermatitis.

The management plan for treating widespread severe atopic dermatitis (eczema) is not directly addressed in the provided drug labels. However, for mild to moderate atopic dermatitis, the management plan involves applying a thin layer of ELIDEL Cream 1% to the affected skin twice daily, stopping use when symptoms resolve, and re-examining the patient if symptoms persist beyond 6 weeks 2.

• Key points:
  • Apply a thin layer of ELIDEL Cream 1% to the affected skin twice daily
  • Stop using when signs and symptoms resolve
  • Re-examine the patient if symptoms persist beyond 6 weeks
• Important considerations:
  • Continuous long-term use of ELIDEL Cream should be avoided
  • Application should be limited to areas of involvement with atopic dermatitis
  • ELIDEL Cream should not be used with occlusive dressings 2

From the Research

Management Plan for Treating Widespread Severe Atopic Dermatitis (Eczema)

The management plan for treating widespread severe atopic dermatitis (eczema) involves a combination of topical and systemic treatments.

• Basic therapy is focused on treating disturbed barrier function by hydrating and lubricating topical treatment, besides further avoidance of specific and unspecific provocation factors 3.
• Topical anti-inflammatory treatment based on glucocorticosteroids and calcineurin inhibitors is used for flare management and for proactive therapy for long-term control 3.
• Topical corticosteroids remain the mainstay of therapy, whereas tacrolimus and pimecrolimus are preferred in sensitive skin areas and for long-term use 3, 4, 5.
• Systemic immunosuppressive agents, such as cyclosporine, are recommended for patients with atopic eczema in whom disease activity cannot be controlled adequately with topical treatments 6.
• Other treatment options, such as phototherapy, antimicrobial therapy, and educational interventions, may also be considered 3, 7.

Topical Anti-Inflammatory Treatments

Topical anti-inflammatory treatments, such as topical corticosteroids, calcineurin inhibitors, and phosphodiesterase-4 inhibitors, are effective in reducing eczema symptoms 7.

• Potent topical corticosteroids, such as very potent TCS, are consistently ranked as amongst the most effective topical anti-inflammatory treatments for eczema 7.
• Tacrolimus 0.1% and ruxolitinib 1.5% are also ranked as most effective, with moderate confidence 7.
• Mild TCS, roflumilast 0.15%, and crisaborole 2% are ranked as least effective 7.

Systemic Treatments

Systemic immunosuppressive agents, such as cyclosporine, are recommended for patients with atopic eczema in whom disease activity cannot be controlled adequately with topical treatments 6.

• Cyclosporine is recommended as first option for patients with atopic eczema refractory to conventional treatment 6.
• Other systemic treatments, such as interferon-γ and azathioprine, may also be considered 6.

Adjuvant Therapy

Adjuvant therapy, such as UV irradiation, may be used in addition to topical and systemic treatments 3.

• UV irradiation, preferably with UVB 311 nm or UVA1, may be used to reduce eczema symptoms 3.