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Guidelines for Management of Atopic Dermatitis: Part III — Management and Treatment with Phototherapy and Systemic Agents

Guideline Watch |
June 11, 2014

Guidelines for Management of Atopic Dermatitis: Part III — Management and Treatment with Phototherapy and Systemic Agents

  1. Craig A. Elmets, MD

Recommendations indicate a need for change in some widespread practices.

  1. Craig A. Elmets, MD

Sponsoring Organization: American Academy of Dermatology

Target Population: Primary care providers, dermatologists

Background and Objective

Most atopic dermatitis (AD) can be managed with topical therapies. However, in some patients with moderate or severe disease and in those on whom the disease has a significant physical, emotional, or social impact, phototherapy or systemic medication may be necessary.

Key Points

Phototherapy

The following forms of phototherapy have been found effective when aggressive topical therapy does not provide adequate control:

  • Narrowband and broadband ultraviolet B (UVB) light

  • UVA1

  • Combined UVA/UVB

  • Psoralen plus UVA (PUVA)

  • The Goeckerman regimen

Systemic Therapy

This is indicated for adults and children with no response to optimized topical regimens or phototherapy and those with substantially affected quality of life.

Evidence-based data on cyclosporine, methotrexate, mycophenolate mofetil, and azathioprine are available. All have significant toxicities that require careful monitoring and should be used at the lowest dose that achieves control and for no longer than necessary:

  • Cyclosporine is effective within 2 to 6 weeks of initiation. Both the modified microemulsion and nonmodified formulations are effective, but they are not bioequivalent and cannot be substituted for one another.

  • Thiopurine methyltransferase levels should be obtained before starting azathioprine, because different polymorphisms in TPMT are associated with varying risk for myelotoxicity.

  • Phototherapy should be avoided in patients taking cyclosporine or azathioprine because of photocarcinogenic effects.

  • Interferon-γ has shown efficacy in double-blind, placebo-controlled trials and can be considered in AD recalcitrant to other systemic medications.

  • Systemic corticosteroids should be avoided because the temporary benefit is outweighed by short- and long-term risks. Because of their rapid action, short courses may be considered during acute flares or in severe disease as a transition to phototherapy or systemic, nonsteroidal immunomodulatory medications.

  • Oral antibiotics are recommended only when there is clear evidence of active Staphylococcus aureus infection.

  • Sedating and nonsedating antihistamines have been evaluated in the management of AD. Sedating antihistamines may improve quality of life by reducing loss of sleep, but there is insufficient evidence to show effectiveness in reducing disease activity. In the absence of an urticarial component, nonsedating antihistamines are not recommended.

Comment

This guideline, based on objective evaluation of the data, produces recommendations that contrast with some widespread practices, including the long-term use of systemic steroids to control the disease, the use of oral antimicrobial agents in the absence of overt infection, and the use of antihistamines other than for sedation to reduce sleep disturbances.

  • Disclosures for Craig A. Elmets, MD at time of publication Consultant / Advisory board Astellas Pharmaceuticals Grant / Research support NIH; NIH/NCI; Veteran’s Administration; Ferndale Laboratories; Abbvie Editorial boards Cancer Prevention Research; Photodermatology, Photoimmunology, & Photomedicine; UpToDate; eMedicine; Journal of Dermatological Sciences Leadership positions in professional societies American Academy of Dermatology (Chair, Clinical Guidelines and Research Committee); Photomedicine Society (Board of Directors)

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