What is atopic dermatitis (also known as eczema)?

From the Guidelines

Atopic dermatitis is a chronic, relapsing inflammatory skin condition that requires a multifaceted approach to management, including patient education, trigger avoidance, skin hydration, anti-inflammatory therapy, and infection control, with the goal of reducing morbidity, mortality, and improving quality of life. The condition typically presents in early childhood but can persist into adulthood, affecting approximately 20% of children and 1-3% of adults in Australia, as noted in the guidelines of care for the management of atopic dermatitis 1. The pathophysiology involves a complex interplay between genetic predisposition, immune dysregulation with Th2 predominance, skin barrier dysfunction, and environmental triggers.

Diagnosis and Assessment

Diagnosis is clinical, based on the presence of pruritic, eczematous lesions with typical morphology and distribution (flexural surfaces in children, hands and face in adults), personal or family history of atopy, and chronicity, as outlined in the guidelines of care for the management of atopic dermatitis: section 1 1. The guidelines also discuss methods for diagnosis and monitoring of disease, outcomes measures for assessment, and common clinical associations that affect patients with AD.

Management and Treatment

Management requires a step-wise approach, starting with:

• Liberal use of emollients and moisturizers applied at least twice daily, even during disease remission
• Topical corticosteroids as the mainstay of anti-inflammatory therapy, with potency selected based on severity, body site, and patient age
• Topical calcineurin inhibitors (tacrolimus 0.03-0.1%, pimecrolimus 1%) for moderate-severe disease, particularly for sensitive areas
• Systemic therapy, including oral immunosuppressants (cyclosporine 3-5mg/kg/day, methotrexate 10-25mg weekly, azathioprine 1-3mg/kg/day), or biologics like dupilumab (initial 600mg followed by 300mg every two weeks) for severe or refractory cases, as recommended by the expert panel of the international eczema council 1
• Phototherapy (narrowband UVB) for widespread disease
• Antihistamines for sleep disturbance, but with limited effect on daytime pruritus
• Treatment of bacterial superinfection, particularly with Staphylococcus aureus, with appropriate antibiotics

Patient Education and Long-term Management

Patient education regarding the chronic nature of the disease, proper bathing practices (short, lukewarm showers), and trigger avoidance (allergens, irritants, stress) is essential for long-term management, as emphasized in the guidelines of care for the management of atopic dermatitis: section 3 1. The guidelines also discuss the management of atopic dermatitis with phototherapy and systemic agents, including indications for use and the risk-benefit profile of each treatment option.

Key considerations in the management of atopic dermatitis include:

• The importance of a multifaceted approach to management
• The need for patient education and trigger avoidance
• The role of topical and systemic therapies in reducing inflammation and improving symptoms
• The importance of monitoring for bacterial superinfection and treating promptly when necessary
• The need for ongoing management and follow-up to prevent flares and improve quality of life, as noted in the guidelines of care for the management of atopic dermatitis: section 3 1.

From the FDA Drug Label

CLINICAL STUDIES Three randomized, double-blind, vehicle-controlled, multi-center, Phase 3 studies were conducted in 589 pediatric patients ages 3 months-17 years old to evaluate ELIDEL ® (pimecrolimus) Cream 1% for the treatment of mild to moderate atopic dermatitis Two of the three trials support the use of ELIDEL Cream in patients 2 years and older with mild to moderate atopic dermatitis A total of 403 pediatric patients 2-17 years old were included in the studies. At endpoint, based on the physician’s global evaluation of clinical response, 35% of patients treated with ELIDEL Cream were clear or almost clear of signs of atopic dermatitis compared to only 18% of vehicle-treated patients.

Atopic Dermatitis is a condition that can be treated with pimecrolimus (TOP) cream.

• The treatment of atopic dermatitis with pimecrolimus (TOP) cream has been studied in pediatric patients ages 3 months-17 years old.
• Clinical studies have shown that pimecrolimus (TOP) cream is effective in treating mild to moderate atopic dermatitis in patients 2 years and older.
• The efficacy of pimecrolimus (TOP) cream in treating atopic dermatitis has been demonstrated by a significant reduction in erythema and infiltration/papulation.
• Pimecrolimus (TOP) cream can be used to treat atopic dermatitis affecting the face and/or neck region.
• Patients using pimecrolimus (TOP) cream should be monitored for local symptoms such as skin burning or pruritus.
• Pimecrolimus (TOP) cream should be used for short periods, and if needed, treatment may be repeated with breaks in between 2.
• Precautions should be taken when using pimecrolimus (TOP) cream, including avoiding malignant or pre-malignant skin conditions and resolving bacterial or viral infections before commencing treatment 2.

From the Research

Definition and Pathophysiology of Atopic Dermatitis

• Atopic dermatitis (atopic eczema) is a chronic relapsing and remitting inflammatory skin disease affecting one in 10 people in their lifetime 3.
• It is caused by a complex interaction of immune dysregulation, epidermal gene mutations, and environmental factors that disrupt the epidermis, causing intensely pruritic skin lesions 3.

Diagnostic Criteria

• The American Academy of Dermatology has created simple diagnostic criteria based on symptoms and physical examination findings 3.

Treatment Options

• Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers 3.
• Use of topical corticosteroids is the first-line treatment for atopic dermatitis flare-ups 3, 4, 5.
• Pimecrolimus and tacrolimus are topical calcineurin inhibitors that can be used in conjunction with topical corticosteroids as first-line treatment 3, 4.
• Ultraviolet phototherapy is a safe and effective treatment for moderate to severe atopic dermatitis when first-line treatments are not adequate 3.
• Antistaphylococcal antibiotics are effective in treating secondary skin infections 3, 6.
• Oral antihistamines are not recommended because they do not reduce pruritus 3.
• Newer medications approved by the U.S Food and Drug Administration, such as crisaborole and dupilumab, are effective in treating atopic dermatitis but are currently cost-prohibitive for most patients 3, 5.

Management and Proactive Therapy

• Proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare 6.
• A stepwise approach is needed to consider alternative therapies and diagnoses before advancing to systemic treatment 5.
• Emerging topical agents are in clinical trials, and several options are now available for topical treatment 5.

Systemic Therapy

• Dupilumab, an interleukin-4 receptor inhibitor, has become first-line systemic therapy given its efficacy and safety, allowing long-term treatment without laboratory monitoring 5.
• Other biologics and Janus kinase inhibitors are emerging as alternatives that could eliminate the need for immunosuppressants with their higher risks 5.