What is the recommended treatment for severe atopic dermatitis?

Treatment Recommendations for Severe Atopic Dermatitis

For severe atopic dermatitis, dupilumab is strongly recommended as first-line systemic therapy due to its excellent efficacy and safety profile. 1

First-line Topical Treatments

Before advancing to systemic therapy, optimize topical treatments:

• Liberal use of emollients and daily bathing with soap-free cleansers as maintenance therapy 2
• Topical corticosteroids (TCS) are the primary treatment for flare-ups 1
  • For severe resistant lesions, consider clobetasol propionate with hydrocolloid occlusive dressing once weekly 3
  • Limit duration of potent TCS in sensitive areas (face, neck, skin folds) to avoid skin atrophy 1
• Topical calcineurin inhibitors (TCIs) are effective steroid-sparing agents for both acute and maintenance therapy 1
  • Consider preceding use with TCS to lessen severity of cutaneous reactions 1
• Proactive therapy with twice-weekly application of TCS or TCI to previously affected areas helps prevent relapses 1
• Wet-wrap therapy with TCS is an effective short-term second-line treatment for moderate to very severe AD 1

Phototherapy

When topical treatments fail to control severe atopic dermatitis:

• Phototherapy is recommended for recalcitrant AD after failure of first-line topical treatments 1
• Narrowband UVB is generally preferred 1
• Not recommended for children younger than 12 years due to unclear long-term safety 1
• Consider potential long-term risks including premature skin aging and cutaneous malignancies 1

Systemic Therapies

For severe AD unresponsive to topical treatments and phototherapy:

Biologics and JAK Inhibitors (First-line Systemic Options)

• Dupilumab (strongly recommended): First FDA-approved targeted systemic treatment for AD 1, 4

  • Dosage for adults: Initial dose of 600 mg (two 300 mg injections), followed by 300 mg every 2 weeks 4
  • Excellent safety profile with few major concerns after 5+ years in clinical practice 1

• Tralokinumab (strongly recommended): Second biologic approved for AD, targeting IL-13 1

  • Somewhat less effective than dupilumab at 16 weeks of treatment 1

• JAK inhibitors (strongly recommended): Abrocitinib, baricitinib, and upadacitinib 1

  • Higher doses may be more efficacious than standard dupilumab dosing 1

Traditional Immunomodulators (Second-line Systemic Options)

• Cyclosporine (conditionally recommended): Rapid onset of action 1

  • Monitor blood pressure, renal function, and drug interactions 1

• Methotrexate (conditionally recommended): Consider for long-term management 1

  • Requires monitoring of liver enzymes and complete blood count 1

• Azathioprine (conditionally recommended): Effective but requires close monitoring 1

  • Dosing may be guided by TPMT enzyme activity 1

• Mycophenolate mofetil (conditionally recommended): Consider after other options 1

Treatments NOT Recommended

• Systemic corticosteroids are conditionally recommended against due to rebound flares and adverse effects 1

  • May be considered only for short-term bridge therapy to other systemic treatments 1

• Systemic antibiotics are not recommended unless there is clinical evidence of infection 1

• Topical antibiotics for long-term use are not recommended due to risk of resistance and sensitization 1

• Non-sedating antihistamines are not recommended for routine treatment in the absence of urticaria 1

  • Short-term use of sedating antihistamines may help with sleep disturbance from pruritus 1

Important Considerations

• Assess disease severity and impact on quality of life before selecting treatment 1
• Rule out alternative diagnoses like contact dermatitis or cutaneous lymphoma when AD is refractory to standard treatments 1
• Most patients will use evidence-based topical therapies concomitantly with phototherapy and systemic therapies 1
• Monitor for potential side effects specific to each treatment modality 1
• Consider the patient's comorbidities when selecting systemic therapy 1