What is the best intervention for atopic dermatitis (also known as eczema)?

From the Guidelines

The most effective intervention for atopic dermatitis is a multi-faceted approach that includes emollients, prescription topical therapies, and consideration of phototherapy or systemic therapies for severe cases, as recommended by the recent American Academy of Dermatology guidelines 1. When managing atopic dermatitis, it's crucial to start with basic skin care measures such as daily application of thick, fragrance-free moisturizers to repair the skin barrier. For mild to moderate flares, topical corticosteroids or non-steroidal alternatives can be effective. However, for more severe or widespread disease, or when there's a significant impact on quality of life, phototherapy or systemic therapies such as dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib should be considered, based on the latest evidence 1.

Key considerations in the management of atopic dermatitis include:

• The use of emollients and topical anti-inflammatory medications as first-line treatments
• The consideration of phototherapy for patients with severe disease or those whose disease is refractory to topical therapy
• The use of systemic therapies, including biologics and Janus kinase inhibitors, for patients with severe disease or significantly impaired quality of life
• The importance of shared decision-making between patients and clinicians when initiating advanced therapies
• The need for ongoing monitoring of the long-term safety of systemic medications for atopic dermatitis, as highlighted by the gaps in current evidence 1.

In terms of specific treatments, dupilumab, tralokinumab, abrocitinib, baricitinib, and upadacitinib are strongly recommended for the management of atopic dermatitis in adults, based on the latest guidelines from the American Academy of Dermatology 1. These treatments have been shown to be effective in improving disease control and quality of life for patients with severe or refractory disease. However, the decision to initiate these therapies should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.

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 In these studies, patients applied either ELIDEL Cream or vehicle cream twice daily to 5% to 96% of their BSA for up to 6 weeks 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.

The best intervention for atopic dermatitis, according to the provided study, is the use of ELIDEL Cream (pimecrolimus), applied twice daily for up to 6 weeks. This treatment has been shown to be effective in 35% of patients, resulting in them being clear or almost clear of signs of atopic dermatitis, compared to 18% of vehicle-treated patients 2.

• Key benefits of this treatment include:
  • Improvement in pruritus (57% of patients had mild or no pruritus at 6 weeks)
  • Reduction in erythema and infiltration/papulation by day 8
  • Significant treatment effect seen by day 15

From the Research

Treatment Options for Atopic Dermatitis

The best intervention for atopic dermatitis involves a combination of lifestyle changes, topical treatments, and systemic therapies. Some key points to consider include:

• Maintenance therapy consists of liberal use of emollients and daily bathing with soap-free cleansers 3
• Topical corticosteroids are the first-line treatment for atopic dermatitis flare-ups, with pimecrolimus and tacrolimus as alternative options 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, while oral antihistamines are not recommended due to lack of efficacy in reducing pruritus 3

Topical Corticosteroids

Topical corticosteroids are classified by strength and the risk of adverse effects, with lower potencies and shorter durations recommended for use in children 4. Key points to consider include:

• The risk of adverse effects increases with prolonged use, large area of application, higher potency, occlusion, and application to areas of thinner skin 4
• Topical corticosteroids can work safely and effectively in patients who are pregnant or lactating, and are available in various formulations such as ointments, creams, and lotions 4
• Correct patient application is critical to successful use, with the fingertip unit method recommended for teaching patients how to apply topical corticosteroids 4

Systemic Therapies

Systemic therapies may be required when atopic dermatitis is not adequately controlled with topical medications. Some options include:

• Cyclosporine A, azathioprine, methotrexate, and mycophenolate mofetil, which are prescribed off-label in the United States 5, 6
• Dupilumab, an FDA-approved biologic for patients with moderate-to-severe atopic dermatitis 7, 6
• Emerging systemic therapies currently under investigation, such as crisaborole, a topical phosphodiesterase 4 inhibitor 7