Prescription Therapies for Atopic Dermatitis
| Treatment for Mild-Moderate Atopic Dermatitis (Topical) | ||||
|---|---|---|---|---|
| Therapy | Indication | Dosage and Scheduling | Side Effect | Pearls |
| Topical corticosteroids (TCS)± Antistaphylococcal antibiotics* (fucidic acid, mupirocin, bacitracin/polymyxin B, ozenoxacin 1%) | First-line prescription therapy if uncontrolled by moisturizers/irritant avoidance | Mild lesions: moderate potency for 2 to 4 weeks Acute flares: high potency for up to 2 weeks Apply 1× to 2× daily | Steroid atrophy, purpura, telangiectasia, striae, focal hypertrichosis, acneiform or rosacea-like eruptions, allergic contact dermatitis, impairment of wound healing | High potency TCS for areas of high absorption acceptable for 5 to 7 days before tapering |
| Topical calcineurin inhibitors (TCIs) | Second-line treatment of mild-to-moderate atopic dermatitis in patients aged 2 years and above (aged 3 months and above for pimecrolimus) | On-label dosing | Potential black box warning, temporary application-site burning | Avoid use on suspected eczema herpeticum; tacrolimus is also indicated for maintenance treatment to prevent flares |
| Topical PDE-4 inhibitors | First-line treatment of mild-to-moderate atopic dermatitis in patients aged 2 years and above | On-label dosing | Transient application-site burning | |
| Treatment for Severe Atopic Dermatitis | ||||
| Phototherapy | Failure of topical treatments | 2× to 5× weekly administration | Erythema, sunburn, advanced skin-aging, itching, nausea | Burdensome and expensive |
| Systemic immunosuppressants (eg, methotrexate [MTX], microphenylate mofetil [MMF], and azathioprine [AZA]) | Failure of topical treatments | MTX: 15 mg/week (adults) MMF: 0.5 to 3 g/day (adult) or 40 to 50 mg/kg/day (pediatric) AZA: 1 to 3 mg/kg/day (adult) | Gastrointestinal upset, nausea, vomiting, fatigue, hepatotoxicity, bone marrow suppression, idiopathic pulmonary fibrosis, teratogenicity, headache, leukopenia, hypersensitivity, bloating, anorexia | Order tuberculosis test, chest radiograph, hepatitis serologies, and ensure immunizations are up to date |
| Dupilumab | Failure of topical treatments | 600 mg subcutaneous loading dose followed by 300 mg subcutaneous dose every 2 weeks | Hypersensitivity reactions, anaphylaxis, injection site reactions, conjunctivitis | High cost, no baseline investigations or routine laboratory monitoring required |
↵* Topical antistaphylococcal antibiotics should be used as an adjunct to TCS treatment in the presence of signs of mild infection concurrent with atopic dermatitis. Combination topical steroid and antibiotic creams exist.
Tcs, topical corticosteroids; Tci, topical calcineurin inhibitors; PDE-4, Phosphodiesterase-4 inhibitor; mtx, methotrexate; mmf, microphenylate mofetil; aza, azathioprine.