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Chapter 1: Atopic Dermatitis

Wenelia Baghoomian; Michael Jacobson; Eric Simpson

ATOPIC DERMATITIS

Therapeutic Approach

Atopic dermatitis is a chronic inflammatory skin disease most commonly occurring in children with a variable course, but can also first appear in adulthood. Therapy should be approached on the basis of disease severity, which includes the intensity of skin lesions, the extent of body surface involvement, symptom burden, and the rapidity of recurrent disease after clearance. Mild disease usually responds to intermittent low-potency topical corticosteroids (TCS), with bland emollients effective for prevention of flares. Moderate-to-severe disease usually requires a combination approach of TCS for clearance and the use of nonsteroidal topical therapies to safely maintain control in a reactive or proactive fashion. Patients with moderate-to-severe disease not controlled with topical therapies should be considered for phototherapy or systemic therapy.1 See Table 1-1.

Table 1-1Atopic Dermatitis Treatment Table
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Table 1-1 Atopic Dermatitis Treatment Table
MEDICATION NAME INDICATION MECHANISM OF ACTION DOSING ADVERSE EFFECTS (SELECTED AEs OF INTEREST) SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy
Corticosteroidsa Any severity. 7 classes of potency. Choice of medication reflects disease severity, location, and patient age Anti-inflammatory Lowest potency (face/anogenital area): hydrocortisone 1% ointment BID; highest potency (palms/soles): clobetasol propionate 0.05% ointment BID Skin irritation, skin atrophy, purpura, telangiectasia, striae, focal withdrawal syndrome, and acneiform or rosacea-like eruption Periodic monitoring for cutaneous changes by physical examinationb IA2
Calcineurin inhibitorsf

Mild-to-moderate disease: pimecrolimus

Moderate-to-severe disease: tacrolimus

 Anti-inflammatory

Pimecrolimus 1% cream BID; tacrolimus 0.03%, 0.1% ointment BID

Pediatric > 2 y/o: pimecrolimus 1% cream BID; tacrolimus 0.03% ointment BID until age 15c

 Skin irritation (burning sensation, stinging pruritus, erythema) None IA3
Crisaborolea Mild-to-moderate disease Phosphodiesterase 4 (PDE-4) inhibitor Adults and pediatric patients ages 3 months and up: 2% ointment BID Application site pain None IA4
Ruxolitinibf Mild-to-moderate disease Janus kinase 1 and 2 inhibitors; immunomodulators Adults and pediatric patients ages 12 and up: 1.5% cream BID, limited to 20% BSA Nasopharyngitis None 1B5
Emollients Mild-to-severe disease Occlusive and humectant agent

Apply BID-TID up to 500 g weekly

Pediatric: apply BID-TID, up to 150-200 g weekly

 Folliculitis, contact dermatitis None IA6
Systemic Therapy
Azathioprinef Moderate-to-severe disease Immunosuppressive

1-3 mg/kg QD

Pediatric: 1-4 mg/kg QD

 Pregnancy category D, bone marrow suppression, increased risk of infections and malignancies, GI symptoms, hypersensitivity syndrome, pancreatitis, hepatitis

Baseline: TPMT. Twice/monthly × 2 mo, monthly × 4 mo, then every other month with dose increase: CBC/differential/platelets, renal function, LFTs.

Annually: hepatitis B and C, TB, HIV, and HCG if indicated

 IA7
Cyclosporinef Moderate-to-severe disease (Maximum 1 y of treatment recommended) Immunosuppressive

Adult: 2.5-5 mg/kg divided BID

Pediatric: 3-6 mg/kg divided BID

 Pregnancy category C, headache, renal impairment, electrolyte disorders, HTN, tremors, paresthesia, hypertrichosis, gingival hyperplasia, GI symptoms, increased risk of infection and malignancies

Every visit: blood pressure.

Every 2 wk for 2-3 mo, then monthly: renal function, LFTs, ...

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