What is the treatment for atopic dermatitis with elevated eosinophils?

Treatment of Atopic Dermatitis with High Eosinophils

For atopic dermatitis with elevated eosinophils, biologics targeting the Th2 inflammatory pathway, such as dupilumab and tralokinumab, are strongly recommended as they directly address the underlying pathophysiology.

First-Line Treatment Approach

• Apply ceramide-containing moisturizers immediately after bathing to repair skin barrier dysfunction, which is essential for both acute treatment and prevention of flares 1
• Use topical corticosteroids for active lesions, selecting potency based on severity and location of eczema 1
• Implement proactive maintenance therapy with topical corticosteroids (1-2× weekly) or topical calcineurin inhibitors (2-3× weekly) to previously affected areas after disease stabilization to prevent flares 1, 2
• Avoid irritants such as soaps, detergents, and products with fragrances and preservatives that can worsen skin barrier dysfunction 1, 2
• Use dispersible creams as soap substitutes for cleansing the skin 1

Second-Line Treatment for Moderate-to-Severe Disease

• Consider phototherapy (particularly narrowband UVB) for patients who fail to respond adequately to optimized topical regimens 1, 2
• For patients with elevated eosinophils, biologics targeting the Th2 inflammatory pathway are particularly effective:
  • Dupilumab and tralokinumab are strongly recommended as they directly address the underlying pathophysiology associated with eosinophilic inflammation 3, 1
  • These biologics have shown significant efficacy in reducing disease severity and improving quality of life 3, 2
• JAK inhibitors (abrocitinib, baricitinib, and upadacitinib) are also strongly recommended for moderate-to-severe disease with eosinophilia 3, 1
• Traditional immunosuppressants (azathioprine, cyclosporine, methotrexate, and mycophenolate) may be considered but have conditional recommendations rather than strong ones 3, 2

Management of Secondary Complications

• Treat secondary bacterial infections with appropriate antibiotics, with flucloxacillin typically being first-line for Staphylococcus aureus 1
• For patients with penicillin allergy, erythromycin is an appropriate alternative 1
• Treat eczema herpeticum with oral acyclovir, or intravenous acyclovir for ill, feverish patients 1

Role of Eosinophils in Atopic Dermatitis

• Eosinophils play a critical role in the development and maintenance of atopic dermatitis, particularly affecting skin barrier function and water loss 4
• Blood eosinophil levels often correlate with disease severity, with higher counts typically seen in more severe cases, especially in patients with personal or family history of respiratory atopy 5
• Targeting the Th2 inflammatory pathway, which drives eosinophilic inflammation, is particularly effective in patients with elevated eosinophils 1, 4

Treatment Algorithm

1. For mild disease:

   • Daily ceramide-containing moisturizers 1, 2
   • Topical corticosteroids or calcineurin inhibitors for active lesions 1, 2
   • Transition to maintenance therapy after clearance 1

2. For moderate-to-severe disease with elevated eosinophils:

   • Continue optimized topical therapy 1
   • Initiate biologics (dupilumab or tralokinumab) as they specifically target the Th2 pathway driving eosinophilic inflammation 3, 1
   • Consider JAK inhibitors as an alternative 3, 1
   • Phototherapy may be used as an adjunct treatment 1, 2

Common Pitfalls to Avoid

• Relying on oral antihistamines as primary treatment for atopic dermatitis itch is ineffective 1, 2
• Using systemic corticosteroids for long-term management is not recommended due to adverse effects 3, 1
• Using systemic antibiotics without evidence of infection should be avoided 1, 2
• Recommending elimination diets based solely on allergy testing results without clear history of food triggers is not advised 1, 2
• Discontinuing topical therapy completely after resolution of acute flares rather than transitioning to maintenance therapy leads to earlier relapse 1, 2
• Failing to recognize the importance of eosinophilia as a marker for potentially more severe disease that may require targeted therapy 4, 5