What alternative treatments are available for a breastfeeding mother with atopic dermatitis who cannot use apremilast?

Alternative Treatments for Atopic Dermatitis in Breastfeeding Mothers

Topical corticosteroids and topical calcineurin inhibitors are the first-line safe and effective treatments for atopic dermatitis in breastfeeding mothers, with both considered safe during lactation. 1

First-Line Topical Therapies (Safe During Breastfeeding)

Topical Corticosteroids

• Topical corticosteroids remain the cornerstone of AD management during lactation and are considered safe for breastfeeding mothers. 1
• Apply to affected areas to rapidly control signs and symptoms, which is critical since AD can negatively impact quality of life and lead to premature cessation of breastfeeding. 1
• Use appropriate potency based on body site and severity; low-potency formulations are permitted on face, axilla, and groin. 2

Topical Calcineurin Inhibitors (Tacrolimus/Pimecrolimus)

• Topical calcineurin inhibitors are equally safe during lactation and serve as steroid-sparing alternatives. 1
• Particularly useful for sensitive areas (face, eyelids, intertriginous zones) where long-term corticosteroid use poses atrophy risk. 2
• Evidence supports both efficacy and safety profiles comparable to topical corticosteroids. 3

Newer Topical Options

• Tapinarof cream receives a strong recommendation from the American Academy of Dermatology for adult AD. 4
• Roflumilast cream (a highly potent PDE4 inhibitor) is FDA-approved for AD and receives a strong AAD recommendation. 4, 5
• These agents lack specific lactation data but represent non-steroidal alternatives with minimal systemic absorption.

Systemic Therapies When Topicals Are Insufficient

Preferred Biologic: Dupilumab

• Dupilumab is the first-line systemic agent for moderate-to-severe AD refractory to topical therapy, with a strong AAD recommendation based on high-certainty efficacy evidence. 6
• While the FDA label notes no human lactation data exist, the drug's large molecular weight (approximately 147 kDa as a monoclonal antibody) suggests minimal transfer into breast milk. 7
• The developmental and health benefits of breastfeeding should be weighed against the mother's clinical need, but dupilumab's pharmacologic profile favors safety. 7

Alternative Biologics

• Tralokinumab is an alternative biologic with strong AAD recommendation, showing comparable safety to dupilumab with slightly lower 16-week efficacy. 6
• Lebrikizumab receives a strong AAD recommendation for AD in adults. 4
• Conjunctivitis is the most common adverse event with IL-4/IL-13 inhibitors; manage with artificial tears and ophthalmology referral if severe. 6

JAK Inhibitors (Use With Caution)

• Upadacitinib, abrocitinib, and baricitinib provide faster itch relief than biologics but carry black-box warnings for serious infections, malignancy, thromboembolism, and cardiovascular events. 6
• These agents require careful risk-benefit assessment in breastfeeding mothers given limited lactation safety data and systemic immunosuppression.
• Reserve for cases requiring rapid symptom control when biologics are contraindicated or ineffective, and only after thorough informed consent. 6

Traditional Immunosuppressants (Conditional Use)

• Cyclosporine is guideline-recommended as first systemic choice during pregnancy but should be limited to short-term bridge therapy (≤1 year) due to nephrotoxicity and hypertension risks. 6, 8
• Despite guideline recommendations, a 2025 international survey revealed cyclosporine is rarely prescribed as the preferred drug by physicians (1.25%), highlighting a gap between guidelines and practice. 8
• Methotrexate, azathioprine, and mycophenolate mofetil are reserved for patients unable to access or afford biologics/JAK inhibitors. 6

Adjunctive and Supportive Measures

Essential Skin Care

• Intensive moisturization with emollients is fundamental to prevent flares and should be recommended universally. 2
• Advise switching to emollient-based wash products and avoiding irritants (soaps, detergents, fragrances). 1
• For nipple eczema specifically in nursing mothers: warm water compresses, black tea compresses, or tannin-containing topicals provide comfort. 1

Stress Management

• Psychological stress is a recognized trigger for AD flares; incorporate stress-reduction interventions such as counseling, relaxation techniques, and cognitive-behavioral therapy. 9
• Actively assess chronic stressors (work, family issues) during clinical encounters to inform individualized treatment plans. 9

Phototherapy

• Narrow-band UVB phototherapy is a conditional recommendation for patients preferring non-systemic options or with contraindications to systemic medications. 6
• Requires frequent clinic visits (typically 2-3 times weekly), which may be challenging for breastfeeding mothers.

Complementary Therapies With Evidence

• Vitamin D supplementation has Level I evidence supporting its use in AD. 10
• Topical vitamin B12, evening primrose oil, and certain botanical oils show preliminary positive results. 10
• Acupuncture, massage, and biofeedback have some supporting evidence for symptom reduction. 10
• Newer complementary options including vitamin E, East Indian Sandalwood Oil, melatonin, and L-histidine show positive preliminary effects but lack sufficient evidence for routine recommendation. 11

Therapies to Avoid

Apremilast

• Apremilast (the drug in question) has insufficient evidence for AD treatment according to AAD guidelines. 6
• The FDA label indicates apremilast is detected in milk of lactating mice at concentrations 1.5-times blood levels, making breastfeeding exposure likely. 7
• Apremilast is FDA-approved only for psoriasis and psoriatic arthritis, not atopic dermatitis. 7

Systemic Corticosteroids

• Systemic corticosteroids receive a conditional recommendation AGAINST use in AD due to rebound flares after discontinuation and long-term adverse effects. 6
• Despite this, a 2025 survey found systemic corticosteroids are still preferred by 42.5% of physicians for acute flares during pregnancy/breastfeeding, demonstrating persistent practice-guideline misalignment. 8

Other Insufficient Evidence Therapies

• Oral antihistamines (except for documented secondary infection), montelukast, ustekinumab, IVIG, interferon-γ, omalizumab, TNF-α inhibitors, and mepolizumab lack sufficient evidence for AD. 6
• While antihistamines are considered by 90.1% of physicians for pregnant/breastfeeding patients, this reflects symptom management rather than disease modification. 8

Common Pitfalls to Avoid

• Do not discontinue breastfeeding prematurely due to unfounded medication safety concerns—topical therapies are safe and effective. 1
• Avoid the misconception that all systemic therapies are contraindicated during lactation—biologics like dupilumab have favorable pharmacokinetic profiles. 7
• Do not rely solely on systemic corticosteroids for acute flares despite their common use—this perpetuates the rebound cycle. 6, 8
• Recognize that physician prescription patterns often diverge from guideline recommendations, particularly regarding cyclosporine and systemic corticosteroids. 8