Biological Therapies for Atopic Dermatitis
Currently, there are no topical biological creams approved for atopic dermatitis treatment; instead, systemic biologics like dupilumab are the recommended biological therapy options for moderate-to-severe cases. 1, 2
First-Line Treatments for Atopic Dermatitis
Topical Therapies
- Emollients and moisturizers are essential for maintaining skin barrier function and should be used liberally as maintenance therapy 1
- Topical corticosteroids remain the mainstay of first-line treatment for atopic dermatitis flares, using the least potent preparation required to control symptoms 1
- Topical calcineurin inhibitors (pimecrolimus cream, tacrolimus ointment) are recommended as second-line topical therapy or as steroid-sparing agents 3, 4
- Pimecrolimus cream 1% has been shown effective in treating mild to moderate atopic dermatitis, with 35% of patients achieving clear or almost clear skin compared to 18% with vehicle 3
Proactive Therapy Approach
- After disease stabilization, continued intermittent application of topical corticosteroids (1-2× per week) or topical calcineurin inhibitors (2-3× per week) to previously affected areas is recommended to prevent flares 1, 5
Systemic Biological Therapies
FDA-Approved Biologics
Dupilumab is strongly recommended as a first-line biologic therapy for adults with moderate-to-severe atopic dermatitis who have failed topical therapies 1, 2
- Standard dosing: 600 mg loading dose, followed by 300 mg every 2 weeks 2
- Treatment response should be assessed at 16 weeks using validated measures 2
- Monitor for ocular symptoms, particularly in the first 4 months of treatment, as dupilumab-related ocular surface disorders occur in approximately 25% of treated individuals 2
Tralokinumab is also strongly recommended for moderate-to-severe atopic dermatitis 1, 6
- Network meta-analyses suggest dupilumab is likely more effective than tralokinumab 6
Other Biological Options
- Newer biologics showing promise include lebrikizumab and nemolizumab, though they have varying levels of evidence supporting their use 6, 7
Systemic Non-Biological Options
JAK Inhibitors
- Oral JAK inhibitors (abrocitinib, baricitinib, and upadacitinib) are strongly recommended for moderate-to-severe atopic dermatitis 1, 6
- Higher doses of abrocitinib and upadacitinib may be more effective than biologics according to network meta-analyses 6
- Biologics are generally considered safer than JAK inhibitors, though safety concerns about JAK inhibitors are mainly extrapolated from older generation medications used in higher-risk populations 6
Traditional Systemic Therapies
- Conditional recommendations exist for phototherapy, azathioprine, cyclosporine, methotrexate, and mycophenolate for moderate-to-severe disease 1, 8
- Systemic corticosteroids are not recommended for long-term management due to adverse effects 1, 2
Special Considerations
Patient Selection for Biologics
- Factors to consider when selecting therapy:
Monitoring and Safety
- For patients on biologics, regular monitoring for treatment response and adverse effects is essential 2, 6
- For dupilumab-related ocular symptoms, preservative-free ocular lubricants are typically effective for mild-to-moderate symptoms 2
- Severe ocular symptoms warrant urgent ophthalmology referral 2
Common Pitfalls to Avoid
- Do not rely on food elimination diets based solely on allergy test results for managing atopic dermatitis 1
- Do not discontinue biologics prematurely due to mild ocular symptoms, as these can often be managed with lubricants 2
- Do not use systemic corticosteroids as long-term therapy, even with inadequate response to biologics 1, 2
- Do not delay treatment of significant ocular symptoms in patients on dupilumab; early intervention reduces risk of complications 2