What is the optimal management for a 77‑year‑old woman with severe atopic dermatitis presenting with extensive scaling, lichenification, and facial and extremity edema?

Management of Severe Atopic Dermatitis with Edema in a 77-Year-Old Woman

This patient requires immediate systemic therapy with dupilumab as first-line treatment, given the severe presentation with extensive scaling, lichenification, and edema that indicates disease not adequately controlled with topical therapies. 1

Immediate Assessment and Diagnostic Considerations

Before initiating systemic therapy, you must rule out secondary bacterial infection and eczema herpeticum:

• Look for increased crusting, weeping, purulent exudate, or pustules – these indicate Staphylococcus aureus superinfection requiring oral flucloxacillin (or erythromycin if penicillin-allergic) while continuing topical corticosteroids. 2
• Watch for grouped vesicles or punched-out erosions – this suggests eczema herpeticum, a medical emergency requiring immediate oral acyclovir (or IV acyclovir if the patient is febrile or systemically ill). 2
• Obtain bacterial cultures if infection is suspected to guide targeted antimicrobial therapy if initial treatment fails. 2

The presence of facial and extremity edema in this context likely represents severe inflammatory disease rather than infection, but you must exclude superinfection before proceeding. 3

First-Line Systemic Treatment: Dupilumab

Dupilumab is FDA-approved for moderate-to-severe atopic dermatitis in adults whose disease is not adequately controlled with topical prescription therapies or when those therapies are not advisable. 1

Dosing for Atopic Dermatitis

• Initial dose: 600 mg subcutaneous (two 300 mg injections at different sites) 1
• Maintenance: 300 mg subcutaneous every 2 weeks 1
• Can be used with or without topical corticosteroids 1

Dupilumab represents the most appropriate first-line systemic agent because it specifically targets the IL-4/IL-13 pathway central to atopic dermatitis pathogenesis, has a favorable safety profile compared to traditional immunosuppressants, and is now the standard of care for severe disease. 4, 5, 6, 7

Concurrent Topical Management

Do not discontinue topical corticosteroids when initiating systemic therapy – they remain essential for controlling active inflammation:

• Apply moderate-to-potent topical corticosteroids (e.g., mometasone furoate 0.1% or clobetasol propionate 0.05%) twice daily to affected areas on the extremities during the acute phase. 2
• For facial involvement, use only low-potency corticosteroids (hydrocortisone 1-2.5%) because facial skin is highly susceptible to steroid-induced atrophy and telangiectasia. 2
• After achieving clearance (typically 2-4 weeks), transition to proactive maintenance: apply the same corticosteroid twice weekly to previously involved skin to reduce subsequent flare risk. 2
• Avoid continuous daily use of very potent corticosteroids – implement "steroid holidays" when feasible. 2

Essential Adjunctive Skin Care

Liberal emollient use is mandatory and provides steroid-sparing benefits:

• Apply fragrance-free emollients immediately after bathing (within 10-15 minutes) to damp skin to create a surface lipid film that reduces transepidermal water loss. 2, 8
• Continue aggressive emollient use even during clear periods – this extends recurrence-free intervals. 2
• Substitute all soaps with soap-free cleansers or dispersible creams because regular soaps strip natural lipids and worsen barrier dysfunction. 2, 8
• Apply emollients after each hand-wash to maintain barrier function. 2

Management of Pruritus

• Sedating antihistamines (hydroxyzine, diphenhydramine) may be used at bedtime to improve nighttime itching through their sedative effect, not direct antipruritic action. 2, 8
• Non-sedating antihistamines have no proven benefit in atopic dermatitis and should not be prescribed. 2, 8
• Keep fingernails short to minimize skin trauma from scratching. 2, 8

Alternative Systemic Options if Dupilumab is Not Available

If dupilumab cannot be accessed due to cost or availability, traditional immunosuppressants may be considered, though they carry greater risks:

• Cyclosporine 3-6 mg/kg/day is typically the first-choice traditional immunosuppressant for moderate-to-severe atopic dermatitis. 4, 6
• Methotrexate 7.5-25 mg/week or azathioprine 1-3 mg/kg/day are alternatives. 2
• Systemic corticosteroids should be avoided for maintenance – they have a limited role only for short-term "tiding over" during acute crises after all other options are exhausted, due to risks of pituitary-adrenal suppression and steroid-related mortality. 2

Phototherapy Consideration

Narrowband UVB phototherapy (312 nm) is an option if systemic therapy is declined or contraindicated, but only after failure of appropriately potent topical corticosteroids with adequate treatment duration and consistent emollient use. 2 However, given the severity with edema in this elderly patient, systemic therapy is more appropriate than phototherapy alone. 3

Critical Pitfalls to Avoid

• Do not delay or withhold topical corticosteroids when infection is present – continue them with appropriate systemic antibiotics. 2
• Do not use potent or very potent corticosteroids on the face – the thin periorbital and facial skin is highly susceptible to atrophy. 2
• Do not prescribe elimination diets based solely on allergy testing – this is not indicated for managing atopic dermatitis. 2
• Do not use empiric systemic antibiotics for colonized or non-infected skin – this promotes resistance without clinical benefit. 2

Follow-Up and Monitoring

• Reassess 48-72 hours after starting any antimicrobial therapy to confirm response. 2
• Evaluate dupilumab response at 4-8 weeks – most patients show significant improvement by this timeframe. 1, 6
• Monitor for conjunctivitis – a known adverse effect of dupilumab that may require ophthalmology referral. 1