From the Guidelines
The treatment of severe atopic dermatitis should prioritize the use of dupilumab, a biologic that targets the IL-4/IL-13 pathway, as the first-line systemic therapy due to its strong recommendation and high efficacy in improving disease control and quality of life, as supported by the latest guidelines from the American Academy of Dermatology 1. When considering treatment options for severe atopic dermatitis, it's essential to take a comprehensive approach that combines topical therapies, systemic medications, and lifestyle modifications. The latest guidelines suggest that for most people with atopic dermatitis, emollients and prescription topical therapies are sufficient to achieve disease control, but for those with more severe or widespread disease, phototherapy or systemic therapies may be necessary to improve disease control and quality of life 1. Some key points to consider in the treatment of severe atopic dermatitis include:
- The use of phototherapy, such as ultraviolet B or ultraviolet A1, which can be effective in improving disease control, although more randomized controlled trial evidence is needed to better understand its role in treatment 1
- The use of systemic therapies, such as oral Janus kinase inhibitors, which have shown strong evidence for improving disease control and quality of life, with medications like abrocitinib, baricitinib, and upadacitinib being recommended 1
- The importance of individualizing treatment based on disease severity, affected areas, patient age, and comorbidities, and using shared decision-making between patients and clinicians to determine the best course of treatment 1
- The need for ongoing monitoring of the long-term safety of systemic medications for atopic dermatitis, with rigorous pharmacovigilance studies being necessary to ensure patient safety 1 In terms of specific treatment options, dupilumab is recommended as a first-line systemic therapy due to its strong evidence and high efficacy in improving disease control and quality of life 1. Other systemic options, such as oral immunosuppressants like cyclosporine, methotrexate, or azathioprine, may also be considered, although more evidence is needed to fully understand their role in treatment 1.
From the FDA Drug Label
Topical corticosteroids such as clobetasol propionate are effective in the treatment of corticosteroid-responsive dermatoses primarily because of their anti-inflammatory, antipruritic, and vasoconstrictive actions. The treatment of severe atopic dermatitis may involve the use of topical corticosteroids such as clobetasol propionate due to their anti-inflammatory and antipruritic effects.
- Clobetasol propionate is a highly potent topical corticosteroid.
- It is essential to use clobetasol propionate as directed by a physician and for the prescribed time period to minimize potential side effects.
- Patients should be monitored for signs of HPA axis suppression and other adverse reactions. 2 3
From the Research
Treatment Options for Severe Atopic Dermatitis
- Systemic corticosteroids are rapidly effective for severe exacerbations, but should only be used short term due to their many long-term side effects 4
- Combination of topical and systemic treatment is often necessary to control the disease 4
- Topical calcineurin inhibitors, such as tacrolimus and pimecrolimus, can be used in conjunction with topical corticosteroids as first-line treatment 5, 6
- Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 5
- Newer medications, such as crisaborole and dupilumab, are effective in treating atopic dermatitis, but are currently cost prohibitive for most patients 5
- Biologics and Janus kinase inhibitors (Jakinibs) are changing the step management of moderate-to-severe atopic dermatitis, but guidelines have yet to provide formal recommendations for their use 7
Systemic Treatment
- Cyclosporin A is rapidly effective, but has a narrow therapeutic index and possible renal toxicity 4
- Azathioprine and methotrexate have a slower onset of action and are good treatment options for many patients, but are not always tolerated 4
- Mycophenolate mofetil, mycophenolate sodium, and biologicals are other alternatives, but need to be assessed in larger randomized trials 4
- Abrocitinib may have better efficacy than dupilumab, but requires closer monitoring for adverse events 7
Topical Treatment
- Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups 5
- Tacrolimus is as effective as class III-V topical corticosteroids for AD of the trunk and extremities, and more effective than low-potency class VI or VII corticosteroids for AD of the face or neck 8
- Pimecrolimus is less effective than both tacrolimus and low-potency topical corticosteroids for moderate to severe AD 8