What is the best course of treatment for a patient with severe atopic dermatitis (eczema) requiring immediate dermatological attention and potential steroid dosing?

From the Guidelines

The patient with severe atopic dermatitis requires immediate dermatological attention and should be started on a potent topical steroid such as clobetasol propionate 0.05% cream twice daily for the body and a lower-potency steroid like hydrocortisone 1% or triamcinolone 0.1% for facial application, for no longer than 2 weeks, as recommended by the most recent guidelines 1.

Key Considerations

• The patient should also use gentle, fragrance-free cleansers and apply thick emollients like petroleum jelly multiple times daily to help manage symptoms.
• Wet wrap therapy can provide relief - apply moisturizer followed by damp bandages and a dry layer overtop.
• An oral antihistamine like hydroxyzine 25mg at bedtime may help reduce itching and improve sleep.
• The patient may need systemic therapy such as prednisone, cyclosporine, or dupilumab, which the dermatologist will determine after evaluation.

Important Evidence

• The guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies recommend the use of phototherapy or systemic therapies to improve disease control and quality of life in patients with severe or widespread AD 1.
• The decision to initiate these more advanced therapies 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.

Next Steps

• Contact a dermatology practice directly and explain that this is an urgent case of severe eczema requiring immediate intervention.
• Emphasize that this is a medical emergency with risk of infection and significant quality of life impairment when calling dermatology offices.
• The dermatologist will determine the best course of treatment, which may include systemic therapy, and rule out other conditions that may be causing symptoms.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION: Apply a thin layer of clobetasol propionate gel, cream or ointment to the affected skin areas twice daily and rub in gently and completely. Clobetasol propionate gel, cream and ointment are super-high potency topical corticosteroids; therefore, treatment should be limited to 2 consecutive weeks, and amounts greater than 50 g per week should not be used. INDICATIONS AND USAGE: Clobetasol propionate gel, cream and ointment are super-high potency corticosteroid formulations indicated for the relief of the inflammatory and pruritic manifestations of corticosteroid responsive dermatoses.

For a patient with severe atopic dermatitis requiring immediate dermatological attention and potential steroid dosing, the best course of treatment is to apply a thin layer of clobetasol propionate gel, cream, or ointment to the affected skin areas twice daily.

• Treatment should be limited to 2 consecutive weeks.
• The total dosage should not exceed 50 g per week to avoid potential suppression of the hypothalamic-pituitary-adrenal (HPA) axis 2 2.
• Therapy should be discontinued when control has been achieved.
• If no improvement is seen within 2 weeks, reassessment of the diagnosis may be necessary.

From the Research

Treatment Options for Severe Atopic Dermatitis

• For patients with severe atopic dermatitis requiring immediate dermatological attention, treatment with systemic medications such as ciclosporin and dupilumab may be effective, as seen in a case study where rapid resolution of flares was achieved with these treatments 3.
• Topical corticosteroids are a common treatment for eczema, and potent or very potent topical corticosteroids may be more effective than mild topical corticosteroids for moderate or severe eczema 4.
• A network meta-analysis found that potent topical corticosteroids, tacrolimus 0.1%, and ruxolitinib 1.5% were among the most effective topical anti-inflammatory treatments for eczema, while mild topical corticosteroids and tapinarof 1% were among the least effective 5.

Steroid Dosing and Treatment Duration

• The optimal duration of treatment with topical corticosteroids is unclear, and there is a need for longer-term trials to determine the best treatment duration 4.
• Applying potent topical corticosteroids once a day may be as effective as twice daily application for treating eczema flare-ups, but the evidence is not conclusive 4.
• Systemic corticosteroids may be used for short-term treatment of severe eczema, but long-term use can have significant side effects, and other treatments such as ciclosporin or dupilumab may be considered for long-term management 3, 6.

Combination Therapies and Alternative Treatments

• Combination therapies, such as topical corticosteroids and antibiotics, may be effective for treating eczema, especially in cases where Staphylococcus aureus colonization is present 7.
• Other treatments, such as phototherapy, cyclosporine, mycophenolic acid precursors, azathioprine, and methotrexate, may be considered for patients with severe or refractory eczema, but the evidence for their effectiveness is limited, and they are often used off-label 6.
• Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, may be effective for treating eczema, especially for patients who are intolerant of topical corticosteroids or have failed other treatments 5.