What is the treatment for severe atopic dermatitis?

Treatment for Severe Atopic Dermatitis

For severe atopic dermatitis, systemic immunomodulators should be considered when topical treatments and phototherapy have failed, with dupilumab being a first-line systemic option for adults and children with moderate-to-severe disease. 1, 2

Step-wise Treatment Approach

First-Line Therapies

• Apply moisturizers liberally after bathing to hydrate the skin and repair the skin barrier, with ceramide-containing formulations being particularly beneficial 2, 3
• Use gentle, soap-free cleansers for bathing to avoid removing natural lipids from the skin 2
• Apply topical corticosteroids (TCS) twice daily during flares until improvement is seen, selecting potency based on location:
  • Medium-potency for thighs and trunk
  • Lower-potency for sensitive areas (face, groin, axillae) 2
• Consider topical calcineurin inhibitors (TCI) as steroid-sparing agents, particularly for sensitive skin areas 4
• After flare resolution, transition to maintenance therapy with TCS (1-2× weekly) or TCI (2-3× weekly) to previously affected areas to prevent recurrence 5, 2

Second-Line Therapies

• Consider wet wrap therapy for moderate-to-severe flares not responding to first-line therapy 2
• Implement phototherapy when first-line treatments fail after 4-8 weeks of optimized therapy, with narrowband UVB generally preferred 2
• Typical dosing schedule for phototherapy: initial UVB at 50% of minimal erythema dose (MED), with treatments 1-20 increased by 10% of initial MED, administered 3-5 times weekly 2

Systemic Treatments for Severe Disease

• Dupilumab (FDA-approved IL-4 receptor antagonist) is recommended for moderate-to-severe atopic dermatitis not adequately controlled with topical prescription therapies 1
  • Adult dosing: Initial 600 mg (two 300 mg injections), followed by 300 mg every 2 weeks 1
  • Pediatric dosing varies by weight 1
• Traditional immunosuppressants may be considered:
  • Cyclosporine (1-4 mg/kg/day) is recommended as first-line traditional immunosuppressant for short-term use 5, 6
  • Azathioprine can be considered as a second-line option, though efficacy is lower 6
  • Methotrexate may be considered as a third-line treatment option 6

Adjunctive Treatments

• Short-term antihistamines may help with sleep disturbance due to pruritus but are not recommended for primary itch control 4, 2
• Consider antimicrobial bleach baths (0.005% sodium hypochlorite) twice weekly in patients prone to skin infections 4
• Systemic antibiotics should only be used when there is clinical evidence of bacterial infection 5, 2
• Educational interventions such as training programs or "eczema schools" are beneficial adjuncts to conventional therapy 5

Treatment Escalation Indicators

• Inadequate response to optimized topical therapy after 4-8 weeks 2
• Extensive body surface area involvement 2
• Significant quality of life impairment 2

Common Pitfalls to Avoid

• Relying on antihistamines as primary treatment for itch rather than addressing inflammation 5, 2
• Using systemic antibiotics without evidence of infection 5, 2
• Discontinuing topical therapy completely after resolution of acute flares, rather than transitioning to maintenance therapy 2, 3
• Recommending elimination diets based solely on allergy testing without clear history of food triggers 5
• Neglecting the importance of patient education in disease management 5

Special Considerations

• For children under 5 years with moderate to severe atopic dermatitis, consider food allergy evaluation only if they have persistent disease despite optimized treatment or a reliable history of immediate reaction after food ingestion 2
• Patch testing should be considered in patients with persistent/recalcitrant disease or suspected allergic contact dermatitis 5