AD Treatment

Goals of Treatment:

  • The overall goal of treatment should be to achieve a state in which symptoms are absent or mild without causing disturbance in activities of daily living, and where drug therapy is not required.
  • If this is not reached, the goal should be to maintain a state in which symptoms are mild and to decrease the rate of “acute flares” or disease exacerbations.

Treatment Interventions:

  • Drug therapy (ie, topical and/or oral)
  • Basic treatment of a disturbed skin barrier—”skin care regimen” (eg, emollients)
  • Control of prurituis using oral antihistamines

Current Treatment Options1-4

  • Topical emollients
  • Topical anti-inflammatory agents (topical corticosteroids and/or topical calcineurin inhibitors)
  • Oral antihistamines (sedating and non-sedating)
  • Crisaborole (PDE-4 inhibitor)
  • Phototherapy (NBUVB or UVA)
  • Oral corticosteroids
  • Other systemic immune suppressants, eg, cyclosporine, methotrexate, and azathioprine
  • Oral antibiotics
  • Dupilumab
  • Adjuvant therapies and approaches, eg, wet wraps, soak-and-smear, and diluted bleach baths
  • Other treatments, eg, omalizumab, rituximab, rapamycin, IVIG, gamma interferon, and systemic tacrolimus (these are not yet FDA-approved for AD)

Please consult product labels for prescribing information on individual therapies.

Considerations for Treatment4-6

  • The majority of patients with mild AD can expect clinical improvement and disease control with use of emollients, conventional topical therapies, and environmental and/or occupational modifications.
  • These interventions may not be sufficient for patients with moderate-to-severe or difficult-to-control disease.
  • Phototherapy and/or systemic therapies for AD:
    • Phototherapy is recommended for both acute and chronic disease.
    • Systemic therapies are recommended for use after failure to achieve disease control with use of above measures.
  • Experimental Agents.
    • JAK Inhibitors – tofacitinib7, baricitinib8 and upadacitinib9 have shown efficacy in phase 2 trials.7-9
    • Anti-IL-31 receptor humanized antibody – nemolizumab has exhibited promise in phase 2 trials.10
    • Anti-IL-13 monoclonal antibody – lebrikizumab is undergoing studies and can potentially provide additional benefit when used with topical corticosteroids as compared with topical corticosteroids alone.11
    • Anti-IL-22 monoclonal antibody – fezakinumab, which blocks IL-22 receptor, is a new agent with promise.12

References

  1. Wang D, et al. Immunologic targets in atopic dermatitis and emerging therapies: An update. Am J Clin Dermatol. 2016;17:425-443.
  2. Roekevisch E, et al. Efficacy and safety of systemic treatments for moderate-to-severe atopic dermatitis: a systematic review. J Allergy Clin Immunol. 2014;133:429-438.
  3. Mohan GC, et al. Comparison of dermatology and allergy guidelines for atopic dermatitis management. JAMA Dermatol. 2015;151:1009-1013.
  4. Wollenberg A et al. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients. J Eur Acad Dermarol Venereol. 2016;30:729-747.
  5. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014;71:327-49.
  6. Saeki H, et al. Clinical practice guidelines for the management of atopic dermatitis 2016. J Dermatol. 2016;43:1117-1145.
  7. Bissonnette R, Papp KA, Poulin Y, et al. Topical tofacitinib for atopic dermatitis: a phase IIa randomized trial. Br J Dermatol. 2016;175:902-911.
  8. Guttman-Yassky E, Silverberg JI, Nemoto O, et al. Baricitinib in adult patients with moderate-to-severe atopic dermatitis: A phase 2 parallel, double-blinded, randomized placebo-controlled multiple-dose study. J Am Acad Dermatol. 2019;80:913-921.e9.
  9. Guttman-Yassky E, Thaçi D, Pangan AL, et al. Upadacitinib in adults with moderate to severe atopic dermatitis: 16-week results from a randomized, placebo-controlled trial. J Allergy Clin 2020;145:877-884.  
  10. Ruzicka T, Hanifin JM, Furue M, et al; XCIMA study group. Anti-interleukin-31 receptor A antibody for atopic dermatitis. N Engl J Med. 2017;376:826-835. 
  11. Simpson EL, Flohr C, Eichenfield LF, et al. Efficacy and safety of lebrikizumab (an anti-IL-13 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by topical corticosteroids: A randomized, placebo-controlled phase II trial (TREBLE). J Am Acad Dermatol. 2018;78:863-871.e11. 
  12. Guttman-Yassky E, Brunner PM, Neumann AU, et al. Efficacy and safety of fezakinumab (an IL-22 monoclonal antibody) in adults with moderate-to-severe atopic dermatitis inadequately controlled by conventional treatments: A randomized, double-blind, phase 2a trial. J Am Acad Dermatol. 2018;78:872-881.e6.