What are the treatment options for eczema (atopic dermatitis) in patients who have failed topical corticosteroids, including clobetasol (Clobetasol), triamcinolone (Triamcinolone), and hydrocortisone (Hydrocortisone)?

From the Guidelines

For patients with eczema who have failed topical corticosteroids like clobetasol, triamcinolone, and hydrocortisone, I recommend trying systemic treatments such as dupilumab (initial dose 600mg subcutaneously, followed by 300mg every other week), which targets IL-4 and IL-13 pathways, as the most recent and highest quality evidence supports its efficacy and safety 1.

Treatment Options

• Systemic treatments: dupilumab, which has been shown to be effective in reducing disease extent and activity, and maintaining improvement 3 months after treatment 1
• Phototherapy: narrowband UVB, which can be effective in reducing inflammation and improving symptoms, administered 2-3 times weekly for 6-12 weeks 1
• Topical treatments: topical calcineurin inhibitors such as tacrolimus (0.03% or 0.1%) or pimecrolimus (1%) applied twice daily to affected areas, and topical phosphodiesterase-4 inhibitors like crisaborole 2% ointment applied twice daily

Important Considerations

• The decision to initiate these more advanced therapies should be made using shared decision-making between patients and clinicians, taking into account the severity of AD, its impact on the patient, and the efficacy, safety, and accessibility of the available interventions 1
• Patients should maintain good skin care with daily lukewarm baths or showers followed immediately by application of fragrance-free moisturizers, avoid known triggers, use gentle cleansers, and wear loose cotton clothing to minimize irritation and help maintain the skin barrier
• The long-term safety of systemic medications for AD should be continuously monitored with rigorous pharmacovigilance studies 1

From the FDA Drug Label

DUPIXENT is indicated for the treatment of adult and pediatric patients aged 6 months and older with moderate-to-severe atopic dermatitis (AD) whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. DUPIXENT can be used with or without topical corticosteroids.

For patients with eczema (atopic dermatitis) who have failed treatment with clobetasol, triamcinolone, and hydrocortisone, dupilumab (DUPIXENT) may be considered as a treatment option.

• Key points:
  • DUPIXENT is indicated for moderate-to-severe atopic dermatitis.
  • It can be used when topical prescription therapies are not adequate or advisable.
  • It can be used with or without topical corticosteroids. 2

From the Research

Treatment Options for Eczema

For patients who have failed clobetasol, triamcinolone, and hydrocortisone, several alternative treatment options are available:

• Narrowband ultraviolet B (NB-UVB) phototherapy: This treatment has been shown to be effective in reducing symptoms of eczema in adults and children 3, 4, 5, 6, 7.
• Ultraviolet A1 (UVA1) phototherapy: This treatment has also been shown to be effective in reducing symptoms of eczema, although the evidence is not as strong as for NB-UVB 5, 6.
• Broadband ultraviolet B (BB-UVB) phototherapy: This treatment has been shown to be less effective than NB-UVB and UVA1 in reducing symptoms of eczema 5, 6.
• Psoralen plus ultraviolet A (PUVA) phototherapy: This treatment has been shown to be effective in reducing symptoms of eczema, although it is not as commonly used as NB-UVB and UVA1 due to the risk of side effects 5, 6.

Efficacy of NB-UVB Phototherapy

NB-UVB phototherapy has been shown to be effective in reducing symptoms of eczema in both adults and children:

• A study published in the Lancet found that NB-UVB phototherapy reduced symptoms of eczema by 61% in adults 3.
• A study published in the British Journal of Dermatology found that NB-UVB phototherapy reduced symptoms of eczema by 61% in children 7.
• A systematic review published in the Cochrane Database of Systematic Reviews found that NB-UVB phototherapy was effective in reducing symptoms of eczema in adults and children, although the evidence was not as strong as for some other treatments 5.

Safety of NB-UVB Phototherapy

NB-UVB phototherapy is generally considered to be safe, although it can cause some side effects:

• A study published in the British Journal of Dermatology found that NB-UVB phototherapy caused no serious side effects in children 7.
• A systematic review published in the Cochrane Database of Systematic Reviews found that NB-UVB phototherapy caused some side effects, including phototoxic reaction, severe irritation, and UV burn, although these were rare 5.