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Yim HJ, Jean T, Ong PY. Comparison of Old and New Systemic Treatments for Moderate to Severe Atopic Dermatitis. Curr Allergy Asthma Rep 2024; 24:289-301. [PMID: 38632138 PMCID: PMC11076369 DOI: 10.1007/s11882-024-01145-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
PURPOSE OF REVIEW Historically, systemic treatments for atopic dermatitis (AD) primarily consisted of immunosuppressive agents such as corticosteroids and Disease Modifying Antirheumatic Drugs (DMARDS), which provided symptomatic relief but often had long-term adverse effects. Newer treatments have shown significant efficacy with less side effects in clinical trials. This review discusses and compares conventional and newer systemic treatments for AD. RECENT FINDINGS Newer medications for AD including dupilumab, tralokinumab, lebrikizumab, and oral JAK inhibitors have been shown to be safe and efficacious. High dose cyclosporine and dupilumab were more effective than methotrexate and azathioprine in improving clinical signs of AD. High-dose upadacitinib was shown in another meta-analysis to be most effective in the measured outcomes but had the highest frequency of adverse events. Targeted biologic treatments are increasingly favored over traditional immunosuppressive treatments of AD. Treatment can be individualized based on potency, adverse side effects, mechanism of action, and administration preference. Ongoing research continues to expand treatment options for AD.
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Affiliation(s)
- Hyun J Yim
- Department of Internal Medicine, Kaiser Los Angeles Medical Center, Los Angeles, CA, USA
| | - Tiffany Jean
- Department of Allergy, Asthma, & Clinical Immunology, Kaiser Los Angeles Medical Center, Los Angeles, CA, USA
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, University of Southern California,, 4650 Sunset Blvd., MS #75, Los Angeles, CA, 90027, USA.
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2
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Moreno A, Renert-Yuval Y, Guttman-Yassky E. Shedding light on key pharmacological knowledge and strategies for pediatric atopic dermatitis. Expert Rev Clin Pharmacol 2023; 16:119-131. [PMID: 36705936 PMCID: PMC9947941 DOI: 10.1080/17512433.2023.2173172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 01/23/2023] [Indexed: 01/28/2023]
Abstract
INTRODUCTION Atopic dermatitis (AD) is an inflammatory disease affecting over 20% of the pediatric population, with 85% of cases presenting before the age of five. Recently, therapeutic options in pediatric patients have evolved rapidly, following extensive development in adult treatments. AREAS COVERED This review will encompass relevant molecular drivers, along with an overlook on treatment modalities in pediatric AD, as well as a summary of pipeline treatments in clinical trials for pediatric patients from PubMed, Google Scholar, and Clinicaltrials.gov up to July 2022. Topical corticosteroids are the mainstay for AD flares in adults and children. Topical approved agents in pediatric AD are calcineurin inhibitors, crisaborolecrisaborole, and ruxolitinib. Dupilumab is the only FDA approved biologic for patients with AD from six months of age. A Janus kinase inhibitor, upadacitinib, is a systemic treatment approved for pediatric AD patients (age >12 years). Systemic immunosuppressants used in pediatric AD include methotrexate, azathioprine, cyclosporinecyclosporine, and mycophenolate mofetil. EXPERT OPINION Data regarding disease prevention are conflicting, however, an abundance of research has transpired regarding amelioration of symptoms and induction of disease clearance by targeting numerous pathological mechanisms. Understanding the pediatric AD phenotype will further advance the field and the development of improved therapeutics.
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Affiliation(s)
- Ariana Moreno
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, NY, USA
| | - Yael Renert-Yuval
- Laboratory for Investigative Dermatology, The Rockefeller University, New York, NY, USA
- Department of Dermatology and the Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Emma Guttman-Yassky
- Department of Dermatology and the Immunology Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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3
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Dodein R, Abdul-Wahab A, Banerjee P. Systemic treatments for atopic dermatitis in children and adolescents: Review of current practice and new treatments. APOLLO MEDICINE 2023. [DOI: 10.4103/am.am_210_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
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4
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Abstract
Background: The treatment of chronic refractory moderate-to-severe atopic dermatitis (AD) has traditionally relied on broad-spectrum systemic anti-inflammatory agents. With the introduction of biologics and Janus kinase inhibitors (Jakinib), the step management of moderate-to-severe AD is rapidly changing; however, guidelines have yet to provide formal recommendations for how to best incorporate these agents into the treatment plan. Objective: To summarize the updated evidence-based medical treatment for AD, including a proposed position for biologics and Jakinibs in the treatment algorithm. Methods: A literature search of several medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from 2012 to 2022 on the treatment of moderate-to-severe AD was conducted to prepare this narrative review. Results: Emollients and topical corticosteroids are the mainstay for treating acute flares and for maintaining chronic control. Second-line topical agents include calcineurin inhibitors, e.g., tacrolimus and pimecrolimus; crisaborole; and ruxolitinib. For acute flares, cyclosporine is preferred over systemic corticosteroids. For chronic treatment, phototherapy should be considered before systemic anti-inflammatory agents. Of the traditional anti-inflammatory agents, cyclosporine is the first-line choice, with methotrexate and azathioprine equal secondary choices. Although abrocitinib may have better efficacy then dupilumab based on indirect comparisons, abrocitinib requires closer monitoring for adverse events. Based on package labeling, Jakinibs, e.g., abrocitinib and upadacitinib, should be used only after failure with other systemic agents, including biologics (e.g., dupilumab and tralokinumab). Biologics and Jakinibs should be considered before the traditional systemic anti-inflammatory agents. Conclusion: Clinicians should consider a modified step management for AD as they await the development of national and international guideline recommendations for how best to position the biologics and Jakinibs into the AD treatment algorithm.
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Fatani MI, Al Sheikh AA, Alajlan MA, Alharithy RS, Binamer Y, Albarakati RG, Alenzi KA, Khardaly AM, Alomari BA, Almudaiheem HY, Al-Jedai A, Eshmawi MT. National Saudi Consensus Statement on the Management of Atopic Dermatitis (2021). Dermatol Ther (Heidelb) 2022; 12:1551-1575. [PMID: 35788543 PMCID: PMC9252549 DOI: 10.1007/s13555-022-00762-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/15/2022] [Indexed: 11/26/2022] Open
Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin disease with an increasing prevalence regionally and globally. It is characterized by intense itching and recurrent eczematous lesions. With the increase in the availability of treatment options for healthcare practitioner and patients, new challenges arise for treatment selection and approach. The current consensus statement has been developed to provide up-to-date evidence and evidence-based recommendations to guide dermatologists and healthcare professionals managing patients with AD in Saudi Arabia. By an initiative from the Ministry of Health (MOH), a multidisciplinary work group of 11 experts was convened to review and discuss aspects of AD management. Four consensus meetings were held on January 14, February 4, February 25, and March 18 of 2021. All consensus content was voted on by the work group, including diagnostic criteria, AD severity assessment, comorbidities, and therapeutic options for AD. Special consideration for the pediatric population, as well as women during pregnancy and lactation, was also discussed. The present consensus document will be updated as needed to incorporate new data or therapeutic agents.
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Affiliation(s)
| | - Afaf A Al Sheikh
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City (National Guard Health Affairs), Riyadh, Saudi Arabia
| | | | - Ruaa S Alharithy
- Princess Nourah Bint Abdul Rahman University, Riyadh, Saudi Arabia
- Security Forces Hospital, Riyadh, Saudi Arabia
| | - Yousef Binamer
- King Faisal Specialist Hospital & Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
| | | | - Khalidah A Alenzi
- Regional Drug Information and Pharmacovigilance Center, Ministry of Health, Tabuk, Saudi Arabia
| | - Amr M Khardaly
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | | | | | - Ahmed Al-Jedai
- Deputyship of Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| | - Maysa T Eshmawi
- King Abdullah Medical Complex, Prince Nayef Street, Northern Abhor, Jeddah, 23816, Saudi Arabia.
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6
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Galli E, Fortina AB, Ricci G, Maiello N, Neri I, Baldo E, Berti I, Bonamonte D, Capra L, Carboni E, Carello R, Caroppo F, Cavagni G, Chinellato I, Cipriani F, Comberiati P, Diociaiuti A, Di Lernia V, Duse M, Filippeschi C, Giannetti A, Giovannini M, Licari A, Marseglia GL, Pace M, Patrizi A, Pajno GB, Peroni D, Villani A, Eichenfield L. Narrative review on the management of moderate-severe atopic dermatitis in pediatric age of the Italian Society of Pediatric Allergology and Immunology (SIAIP), of the Italian Society of Pediatric Dermatology (SIDerP) and of the Italian Society of Pediatrics (SIP). Ital J Pediatr 2022; 48:95. [PMID: 35701810 PMCID: PMC9195338 DOI: 10.1186/s13052-022-01278-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/10/2022] [Indexed: 02/06/2023] Open
Abstract
Currently, there are a few detailed guidelines on the overall management of children and adolescents with moderate-severe atopic dermatitis. AD is a complex disease presenting with different clinical phenotypes, which require an individualized and multidisciplinary approach. Therefore, appropriate interaction between primary care pediatricians, pediatric allergists, and pediatric dermatologists is crucial to finding the best management strategy. In this manuscript, members of the Italian Society of Pediatric Allergology and Immunology (SIAIP), the Italian Society of Pediatric Dermatology (SIDerP), and the Italian Society of Pediatrics (SIP) with expertise in the management of moderate-severe atopic dermatitis have reviewed the latest scientific evidence in the field. This narrative review aims to define a pathway to appropriately managing children and adolescents with moderate-severe atopic dermatitis.
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Affiliation(s)
- Elena Galli
- Pediatric Allergology Unit, Department of Pediatric Medicine, S.Pietro Hospital Fatebenefratelli, Roma, Italy
| | - Anna Belloni Fortina
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Giampaolo Ricci
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Nunzia Maiello
- Department of Woman, Child and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Iria Neri
- Dermatology Unit, IRCCS of Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Hospital, Bologna, Italy
| | - Ermanno Baldo
- Giovan Battista Mattei" Research Institute, Stenico, Italy
| | - Irene Berti
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
| | - Domenico Bonamonte
- Department of Biomedical Science and Human Oncology, Section of Dermatology, University of Bari, Bari, Italy
| | | | - Elena Carboni
- Unit of Paediatrics, Maggiore Hospital, ASST-Cremona, Cremona, Italy
| | - Rossella Carello
- Pediatric Allergology Unit, Department of Pediatric Medicine, S.Pietro Hospital Fatebenefratelli, Roma, Italy
| | - Francesca Caroppo
- Pediatric Dermatology Unit, Department of Medicine, University of Padua, Padova, Italy
| | - Giovanni Cavagni
- Allergology Service European Diagnostic DRP Centre Parma, Parma, Italy
| | | | | | - Pasquale Comberiati
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Andrea Diociaiuti
- Dermatology Unit and Genodermatosis Unit, Genetics and Rare Diseases Research Division, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Vito Di Lernia
- Dermatology Unit, Arcispedale Santa Maria Nuova, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marzia Duse
- Pediatrics, Sapienza University, Rome, Italy
| | - Cesare Filippeschi
- Dermatology Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Arianna Giannetti
- Pediatric Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Massarenti, 11, 40138, Bologna, Italy.
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Amelia Licari
- Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, University of Pavia, Pavia, Italy
| | - Gian Luigi Marseglia
- Clinica Pediatrica Università di Pavia - Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Manuela Pace
- Department of Pediatrics, S. Maria del Carmine Hospital, Rovereto, Italy
| | - Annalisa Patrizi
- Dermatology Unit, IRCCS of Azienda Ospedaliero-Universitaria Policlinico Sant'Orsola Hospital, Bologna, Italy.,Dermatology, Department of Specialistic, Diagnostic and Experimental Medicine (DIMES), Alma MaterStudiorum University of Bologna, Bologna, Italy
| | | | - Diego Peroni
- Department of Clinical and Experimental Medicine, Section of Pediatrics, University of Pisa, Pisa, Italy
| | - Alberto Villani
- Emergency and General Pediatrics Department Bambino Gesù Children Hospital - IRCCS, Rome, Italy
| | - Lawrence Eichenfield
- Department of Dermatology, University of California, San Diego and Rady Children's Hospital, San Diego, USA
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7
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Bose S, Madke B. A comprehensive review of immunosuppressive drugs in pediatric dermatoses: Part II – methotrexate and mycophenolate mofetil. INDIAN JOURNAL OF PAEDIATRIC DERMATOLOGY 2022. [DOI: 10.4103/ijpd.ijpd_84_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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8
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Davari DR, Nieman EL, McShane DB, Morrell DS. Current Perspectives on the Systemic Management of Atopic Dermatitis. J Asthma Allergy 2021; 14:595-607. [PMID: 34103945 PMCID: PMC8179820 DOI: 10.2147/jaa.s287638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/13/2021] [Indexed: 01/07/2023] Open
Abstract
Atopic dermatitis (AD) is a common disease of childhood, and some patients experience a prolonged clinical course into adolescence and adulthood. Systemic management is required when AD is not adequately controlled with topical medications. Our aim is to provide a comprehensive review of commonly used systemic immunomodulating agents in childhood and adult AD, including cyclosporine A (CsA), azathioprine (AZA), methotrexate (MTX) and mycophenolate mofetil (MMF), which are prescribed off-label in the United States, as well as dupilumab, an FDA-approved biologic. We will also provide a brief overview of emerging systemic therapies currently under investigation.
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Affiliation(s)
- Danielle R Davari
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Elizabeth L Nieman
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Diana B McShane
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Dean S Morrell
- Department of Dermatology, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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9
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Mancuso JB, Lee SS, Paller AS, Ohya Y, Eichenfield LF. Management of Severe Atopic Dermatitis in Pediatric Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1462-1471. [PMID: 33838839 DOI: 10.1016/j.jaip.2021.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/05/2021] [Accepted: 02/05/2021] [Indexed: 12/13/2022]
Abstract
Atopic dermatitis is a common, chronic inflammatory skin disorder, present in about 12% of children worldwide. Optimizing management of severe atopic dermatitis in pediatric patients is critical to reduce signs of inflammation, alleviate pruritus and sleep disturbance, minimize the development and/or impact of comorbidities, and improve the patient and caregiver's quality of life. Evaluating the longitudinal severity of pediatric atopic dermatitis is an important component of measuring therapeutic response and long-term management, and is different in clinical practice versus clinical trials. This article describes when and how to use different treatments for pediatric patients with severe atopic dermatitis, including topical medications, phototherapy, and systemic medical therapies (traditional immunosuppressants, biologics, and small molecule inhibitors). It also provides recommendations useful in clinical practice for nonpharmacologic interventions for pediatric patients with severe atopic dermatitis.
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Affiliation(s)
- Jennifer B Mancuso
- Department of Dermatology, University of Michigan Medical School, Ann Arbor, Mich
| | - Stephanie S Lee
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, Calif; Pediatric and Adolescent Dermatology, Rady Children's Hospital San Diego, San Diego, Calif
| | - Amy S Paller
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Lawrence F Eichenfield
- Departments of Dermatology and Pediatrics, University of California San Diego, San Diego, Calif; Pediatric and Adolescent Dermatology, Rady Children's Hospital San Diego, San Diego, Calif.
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10
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Werfel T, Heratizadeh A, Aberer W, Ahrens F, Augustin M, Biedermann T, Diepgen T, Fölster-Holst R, Kahle J, Kapp A, Nemat K, Peters E, Schlaeger M, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Staab D, Traidl-Hoffmann C, Werner R, Wollenberg A, Worm M, Ott H. Aktualisierung„ Systemtherapie bei Neurodermitis“ zur S2k‐Leitlinie Neurodermitis. J Dtsch Dermatol Ges 2021; 19:151-169. [PMID: 33491881 DOI: 10.1111/ddg.14371_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Thomas Werfel
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Annice Heratizadeh
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, Austria
| | | | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Thomas Diepgen
- Institut für Klinische Sozialmedizin, Hautklinik, Universitätsklinikum Heidelberg
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Julia Kahle
- Deutscher Allergie- und Asthmabund (DAAB) e.V., Mönchengladbach
| | - Alexander Kapp
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Katja Nemat
- Praxis für Kinderpneumologie und Allergologie, Kinderzentrum Dresden-Friedrichstadt (Kid), Dresden
| | - Eva Peters
- Klinik für Psychosomatik und Psychotherapie, Universitätsklinikum Gießen (UKGM), Gießen
| | | | | | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsversorgung (ZEGV), Medizinische Fakultät Gustav Carus, Technische Universität Dresden
| | | | - Doris Staab
- Klinik für Pädiatrie m. S. Pneumologie und Immunologie, Charité Campus Virchow-Klinikum, Berlin
| | | | - Ricardo Werner
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin
| | - Andreas Wollenberg
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwigs-Maximilians-Universität, München
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover
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11
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Werfel T, Heratizadeh A, Aberer W, Ahrens F, Augustin M, Biedermann T, Diepgen T, Fölster-Holst R, Kahle J, Kapp A, Nemat K, Peters E, Schlaeger M, Schmid-Grendelmeier P, Schmitt J, Schwennesen T, Staab D, Traidl-Hoffmann C, Werner R, Wollenberg A, Worm M, Ott H. Update "Systemic treatment of atopic dermatitis" of the S2k-guideline on atopic dermatitis. J Dtsch Dermatol Ges 2021; 19:151-168. [PMID: 33491884 DOI: 10.1111/ddg.14371] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
This guideline is an update from August 2020 the S2k-guideline "Atopic dermatitis" published in 2015. The reason for updating this chapter of the guideline were the current developments in the field of systemic therapy of atopic dermatitis. The agreed recommendations for systemic treatment in atopic dermatitis of the present guideline are based on current scientific data. Due to the approval of dupilumab for the treatment of moderate to severe atopic dermatitis, which cannot be treated sufficiently with topical drugs alone, this part of the guideline has now been adapted and newly consented. The indication for systemic therapy and the therapeutic response to topical and systemic treatment should be recorded and documented in a suitable form in clinic and practice. A standardized documentation of the indication for system therapy in atopic dermatitis can be recommended and is also part of the updated chapter of this guideline.
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Affiliation(s)
- Thomas Werfel
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Annice Heratizadeh
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Werner Aberer
- Universitätsklinik für Dermatologie und Venerologie, Medizinische Universität Graz, Austria
| | | | - Matthias Augustin
- Kompetenzzentrum Versorgungsforschung in der Dermatologie (CVderm), Institut für Versorgungsforschung in der Dermatologie und bei Pflegeberufen (IVDP), Universitätsklinikum Eppendorf, Hamburg
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein, Technische Universität München
| | - Thomas Diepgen
- Institut für Klinische Sozialmedizin, Hautklinik, Universitätsklinikum Heidelberg
| | - Regina Fölster-Holst
- Klinik für Dermatologie, Venerologie und Allergologie, Universitätsklinikum Schleswig-Holstein, Campus Kiel
| | - Julia Kahle
- Deutscher Allergie- und Asthmabund (DAAB) e.V., Mönchengladbach
| | - Alexander Kapp
- Abteilung für Immundermatologie und experimentelle Allergologie, Klinik für Dermatologie, Allergologie und Venerologie, Medizinische Hochschule Hannover
| | - Katja Nemat
- Praxis für Kinderpneumologie und Allergologie, Kinderzentrum Dresden-Friedrichstadt (Kid), Dresden
| | - Eva Peters
- Klinik für Psychosomatik und Psychotherapie, Universitätsklinikum Gießen (UKGM), Gießen
| | | | | | - Jochen Schmitt
- Zentrum für Evidenzbasierte Gesundheitsforschung, Technische Universität Dresden
| | | | - Doris Staab
- Klinik für Pädiatrie m. S. Pneumologie und Immunologie, Charité Campus Virchow-Klinikum, Berlin
| | | | - Ricardo Werner
- Klinik für Dermatologie, Venerologie und Allergologie, Division of Evidence-Based Medicine (dEBM), Charité - Universitätsmedizin Berlin
| | - Andreas Wollenberg
- Klinik und Poliklinik für Dermatologie und Allergologie, Ludwigs-Maximilians-Universität, München
| | - Margitta Worm
- Klinik für Dermatologie, Venerologie und Allergologie, Charité - Universitätsmedizin Berlin
| | - Hagen Ott
- Fachbereich Pädiatrische Dermatologie und Allergologie, Kinder- und Jugendkrankenhaus Auf der Bult, Hannover
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Wollenberg A, Christen‐Zäch S, Taieb A, Paul C, Thyssen J, Bruin‐Weller M, Vestergaard C, Seneschal J, Werfel T, Cork M, Kunz B, Fölster‐Holst R, Trzeciak M, Darsow U, Szalai Z, Deleuran M, Kobyletzki L, Barbarot S, Heratizadeh A, Gieler U, Hijnen D, Weidinger S, De Raeve L, Svensson Å, Simon D, Stalder J, Ring J. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children. J Eur Acad Dermatol Venereol 2020; 34:2717-2744. [DOI: 10.1111/jdv.16892] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/10/2020] [Accepted: 07/23/2020] [Indexed: 02/06/2023]
Affiliation(s)
- A. Wollenberg
- Department of Dermatology and Allergy Ludwig‐Maximilian‐University Munich Germany
| | - S. Christen‐Zäch
- Pediatric Dermatology Unit Departments of Dermatology and Pediatrics Centre Hospitalier Universitaire Vaudois Lausanne Switzerland
| | - A. Taieb
- University of Bordeaux Bordeaux France
| | - C. Paul
- Department of Dermatology and Allergy Toulouse University and CHU Toulouse France
| | - J.P. Thyssen
- Department of Dermatology and Allergy Herlev‐Gentofte HospitalUniversity of Copenhagen Hellerup Denmark
| | - M. Bruin‐Weller
- National Expertise Center for Atopic Dermatitis Department of Dermatology and Allergology University Medical Center Utrecht The Netherlands
| | - C. Vestergaard
- Department of Dermatology Aarhus University Hospital Aarhus Denmark
| | - J. Seneschal
- Department of Dermatology National Reference Center for Rare Skin Diseases Bordeaux University Hospitals Bordeaux France
| | - T. Werfel
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - M.J. Cork
- Sheffield Dermatology Research IICDUniversity of Sheffield UK
| | - B. Kunz
- Dermatologikum Hamburg Hamburg Germany
| | - R. Fölster‐Holst
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Kiel Germany
| | - M. Trzeciak
- Department of Dermatology, Venereology and Allergology Medical University of Gdansk Gdansk Poland
| | - U. Darsow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
- ZAUM – Center of Allergy & Environment Munich Germany
| | - Z. Szalai
- Department of Dermatology Heim Pál National Children’s Institute Budapest Hungary
| | - M. Deleuran
- Department of Dermatology Aarhus University Hospital Aarhus Denmark
| | - L. Kobyletzki
- School of Medical Sciences Lund University Malmö Sweden
- School of Medical Sciences Örebro University Örebro Sweden
| | - S. Barbarot
- Department of Dermatology CHU Nantes UMR 1280 PhAN INRA, F‐44000 Nantes Université Nantes France
| | - A. Heratizadeh
- Division of Immunodermatology and Allergy Research Department of Dermatology and Allergy Hannover Medical School Hannover Germany
| | - U. Gieler
- Department of Dermatology University of Gießen and Marburg GmbH Gießen Germany
| | - D.J. Hijnen
- Department of Dermatology Erasmus MC University Medical Center Rotterdam The Netherlands
| | - S. Weidinger
- Department of Dermatology and Allergy University Hospital Schleswig‐Holstein Kiel Germany
| | - L. De Raeve
- Department of Dermatology Universitair Ziekenhuis Brussel (UZB)Free University of Brussels (VUB) Brussels Belgium
| | - Å. Svensson
- Department of Dermatology Skane University Hospital Malmö Sweden
| | - D. Simon
- Department of Dermatology, Inselspital Bern University Hospital University of Bern Bern Switzerland
| | - J.F. Stalder
- Department of Dermatology CHU Nantes UMR 1280 PhAN INRAE, F‐44000 Nantes Université Nantes France
| | - J. Ring
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
- Christiane‐Kühne Center for Allergy Research and Education (CK‐Care) Davos Switzerland
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13
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Sawangjit R, Dilokthornsakul P, Lloyd-Lavery A, Lai NM, Dellavalle R, Chaiyakunapruk N. Systemic treatments for eczema: a network meta-analysis. Cochrane Database Syst Rev 2020; 9:CD013206. [PMID: 32927498 PMCID: PMC8128359 DOI: 10.1002/14651858.cd013206.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Eczema is a common and chronic, relapsing, inflammatory skin disorder. It seriously impacts quality of life and economic outcomes, especially for those with moderate to severe eczema. Various treatments allow sustained control of the disease; however, their relative benefit remains unclear due to the limited number of trials directly comparing treatments. OBJECTIVES To assess the comparative efficacy and safety of different types of systemic immunosuppressive treatments for moderate to severe eczema using NMA and to generate rankings of available systemic immunosuppressive treatments for eczema according to their efficacy and safety. SEARCH METHODS We searched the following databases up to August 2019: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, and Embase. SELECTION CRITERIA All randomised controlled trials (RCTs) of systemic immunosuppressive agents for moderate to severe atopic eczema when compared against placebo or any other eligible eczema treatment. DATA COLLECTION AND ANALYSIS We synthesised data using pair-wise analysis and NMA to compare treatments and rank them according to their effectiveness. Effectiveness was assessed primarily by determining the proportion of participants who achieved at least 75% improvement in the Eczema Area and Severity Index (EASI75) and improvement in the Patient-Oriented Eczema Measure (POEM). Safety was evaluated primarily by considering the proportion of participants with serious adverse events (SAEs) and infection. We deemed short-term follow-up as ≤ 16 weeks and long-term follow-up as > 16 weeks. We assessed the certainty of the body of evidence from the NMA for these primary outcomes using six domains of CiNEMA grading. MAIN RESULTS We included a total of 74 studies, with 8177 randomised participants. Approximately 55% of participants were male, with average age of 32 years (range 2 to 84 years), although age and gender were unreported for 419 and 902 participants, respectively. Most of the included trials were placebo controlled (65%), 34% were head-to-head studies (15% assessed the effects of different doses of the same drug), and 1% were multi-armed studies with both an active comparator and a placebo. All trials included participants with moderate to severe eczema, but 62% of studies did not separate data by severity; 38% of studies assessed only severe eczema. The total duration of included trials ranged from 2 weeks to 60 months, whereas treatment duration varied from a single dose (CIM331, KPL-716) to 60 months (methotrexate (MTX)). Seventy studies were available for quantitative synthesis; this review assessed 29 immunosuppressive agents from three classes of interventions. These included (1) conventional treatments, with ciclosporin assessed most commonly; (2) small molecule treatments, including phosphodiesterase (PDE)-4 inhibitors, tyrosine kinase inhibitors, and Janus kinase (JAK) inhibitors; and (3) biological treatments, including anti-CD31 receptors, anti-interleukin (IL)-22, anti-IL-31, anti-IL-13, anti-IL-12/23p40, anti-OX40, anti-TSLP, anti-CRTH2, and anti-immunoglobulin E (IgE) monoclonal antibodies, but most commonly dupilumab. Most trials (73) assessed outcomes at a short-term duration ranging from 2 to 16 weeks, whereas 33 trials assessed long-term outcomes, with duration ranging from 5 to 60 months. All participants were from a hospital setting. Fifty-two studies declared a source of funding, and of these, pharmaceutical companies funded 88%. We rated 37 studies as high risk; 21, unclear risk, and 16, low risk of bias, with studies most commonly at high risk of attrition bias. Network meta-analysis suggests that dupilumab ranks first for effectiveness when compared with other biological treatments. Dupilumab is more effective than placebo in achieving EASI75 (risk ratio (RR) 3.04, 95% confidence interval (CI) 2.51 to 3.69) and improvement in POEM score (mean difference 7.30, 95% CI 6.61 to 8.00) at short-term follow-up (high-certainty evidence). Very low-certainty evidence means we are uncertain of the effects of dupilumab when compared with placebo, in terms of the proportion of participants who achieve EASI75 (RR 2.59, 95% CI 1.87 to 3.60) at longer-term follow-up. Low-certainty evidence indicates that tralokinumab may be more effective than placebo in achieving short-term EASI75 (RR 2.54, 95% CI 1.21 to 5.34), but there was no evidence for tralokinumab to allow us to assess short-term follow-up of POEM or long-term follow-up of EASI75. We are uncertain of the effect of ustekinumab compared with placebo in achieving EASI75 (long-term follow-up: RR 1.17, 95% CI 0.40 to 3.45; short-term follow-up: RR 0.91, 95% CI 0.28 to 2.97; both very low certainty). We found no evidence on ustekinumab for the POEM outcome. We are uncertain whether other immunosuppressive agents that targeted our key outcomes influence the achievement of short-term EASI75 compared with placebo due to low- or very low-certainty evidence. Dupilumab and ustekinumab were the only immunosuppressive agents evaluated for longer-term EASI75. Dupilumab was the only agent evaluated for improvement in POEM during short-term follow-up. Low- to moderate-certainty evidence indicates a lower proportion of participants with SAEs after treatment with QAW039 and dupilumab compared to placebo during short-term follow-up, but low- to very low-certainty evidence suggests no difference in SAEs during short-term follow-up of other immunosuppressive agents compared to placebo. Evidence for effects of immunosuppressive agents on risk of any infection during short-term follow-up and SAEs during long-term follow-up compared with placebo was of low or very low certainty but did not indicate a difference. We did not identify differences in other adverse events (AEs), but dupilumab is associated with specific AEs, including eye inflammation and eosinophilia. AUTHORS' CONCLUSIONS Our findings indicate that dupilumab is the most effective biological treatment for eczema. Compared to placebo, dupilumab reduces eczema signs and symptoms in the short term for people with moderate to severe atopic eczema. Short-term safety outcomes from clinical trials did not reveal new safety concerns with dupilumab. Overall, evidence for the efficacy of most other immunosuppressive treatments for moderate to severe atopic eczema is of low or very low certainty. Given the lack of data comparing conventional with newer biological treatments for the primary outcomes, there remains high uncertainty for ranking the efficacy and safety of conventional treatments such as ciclosporin and biological treatments such as dupilumab. Most studies were placebo-controlled and assessed only short-term efficacy of immunosuppressive agents. Further adequately powered head-to-head RCTs should evaluate comparative long-term efficacy and safety of available treatments for moderate to severe eczema.
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Affiliation(s)
- Ratree Sawangjit
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mahasarakham University, Mahasarakham, Thailand
| | - Piyameth Dilokthornsakul
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Antonia Lloyd-Lavery
- Department of Dermatology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Nai Ming Lai
- School of Medicine, Taylor's University, Subang Jaya, Malaysia
| | | | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
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14
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Schwartz RA, Pradhan S, Murrell DF, Jafferany M, Olisova OY, Lomonosov KM, Lotti T, Goldust M. COVID-19 and immunosuppressive therapy in dermatology. Dermatol Ther 2020; 33:e14140. [PMID: 32770592 PMCID: PMC7435553 DOI: 10.1111/dth.14140] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/21/2020] [Accepted: 07/25/2020] [Indexed: 12/28/2022]
Abstract
Coronavirus 2019 (COVID 19) was first detected in December 2019 in China. It has become a pandemic. With concern about therapies that may decrease immunity and enhance the severity of an individual's COVID‐19 infection, leading to a possibly fatal outcome, use of immunosuppressants has become an important concern. This work focuses on management of various skin diseases individuals lacking immunity to COVID‐19 but requiring a systemic immunosuppressant, keeping in view the challenge of the COVID 19 pandemic and that our knowledge of this virus and its effects on the immune system are incomplete including knowledge as to an individual's immunity after COVID‐19 infection.
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Affiliation(s)
- Robert A Schwartz
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Swetalina Pradhan
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Patna, India
| | - Dedee F Murrell
- Department of Dermatology, St George Hospital, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mohammad Jafferany
- College of Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Olga Y Olisova
- Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Konstantin M Lomonosov
- Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Torello Lotti
- Department of Dermatology and Venereology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia.,Department of Dermatology, University of Studies Guglielmo Marconi, Rome, Italy
| | - Mohamad Goldust
- University of Studies Guglielmo Marconi, Rome, Italy.,Department of Dermatology, University Hospital Basel, Basel, Switzerland
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15
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Atopic dermatitis. Interdisciplinary diagnostic and therapeutic recommendations of the Polish Dermatological Society, Polish Society of Allergology, Polish Pediatric Society and Polish Society of Family Medicine. Part II. Systemic treatment and new therapeutic methods. Postepy Dermatol Alergol 2020; 37:129-134. [PMID: 32489345 PMCID: PMC7262801 DOI: 10.5114/ada.2020.94829] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 10/04/2019] [Indexed: 01/11/2023] Open
Abstract
The treatment goal in atopic dermatitis is eliminating clinical symptoms of the disease, preventing exacerbations and complications, as well as improving patients’ quality of life. In cases of severe atopic dermatitis and lack of response it is recommended to introduce systemic therapy. Patients ofter require multi-specialist consultations, and occasionally hospitalization. It is not recommended to use acupuncture, acupressure, bioresonance, homeopathy, or Chinese herbs in the treatment of atopic dermatitis.
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16
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17
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Topical and Oral Therapies for Childhood Atopic Dermatitis and Plaque Psoriasis. CHILDREN-BASEL 2019; 6:children6110125. [PMID: 31694234 PMCID: PMC6915686 DOI: 10.3390/children6110125] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/24/2019] [Accepted: 11/01/2019] [Indexed: 02/06/2023]
Abstract
Background: Treatment of atopic dermatitis and psoriasis in children is difficult due to lack of standardized treatment guidelines and few FDA-approved treatment options. Treatments approved for adults may be used off-label in pediatric patients. Objective: This review evaluates the topical and oral treatment options available, including off-label uses, and provides a basic therapeutic guideline for pediatric atopic dermatitis and psoriasis. Methods: A PubMed review of topical and systemic treatments for pediatric psoriasis and atopic dermatitis with information regarding age, efficacy, dosing, contra-indications, adverse events, and off-label treatments. Results: The search identified seven topical and five systemic treatments that are routinely employed to treat pediatric atopic dermatitis and psoriasis. Limitations: Standardized guidelines regarding treatment choice, dosing, and long-term safety are scarce. Reviews may be subject to ascertainment bias. Conclusions: Current treatment guidelines are based on clinical experience and expert advice with few treatments officially approved for atopic dermatitis and psoriasis in children.
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18
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Yun JSW, Yap T, Martyres R, Kern JS, Varigos G, Scardamaglia L. The association of mycophenolate mofetil and human herpes virus infection. J DERMATOL TREAT 2019; 31:46-55. [DOI: 10.1080/09546634.2019.1572864] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Jenny Sung Won Yun
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
| | - Tami Yap
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
- Melbourne Dental School, University of Melbourne, Victoria, Australia
| | - Raymond Martyres
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
| | - Johannes S. Kern
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
| | - George Varigos
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
| | - Laura Scardamaglia
- Departments of Dermatology, Royal Melbourne Hospital, Victoria, Australia
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Australia
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19
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Gür Çetinkaya P, Şahiner ÜM. Childhood atopic dermatitis: current developments, treatment approaches, and future expectations. Turk J Med Sci 2019; 49:963-984. [PMID: 31408293 PMCID: PMC7018348 DOI: 10.3906/sag-1810-105] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Atopic dermatitis (AD) is the most common chronic inflammatory skin disorder of childhood. Underlying factors that contribute to AD are impaired epithelial barrier, alterations in the lipid composition of the skin, immunological imbalance including increased Th2/Th1 ratio, proinflammatory cytokines, decreased T regulatory cells, genetic mutations, and epigenetic alterations. Atopic dermatitis is a multifactorial disease with a particularly complicated pathophysiology. Discoveries to date may be considered the tip of the iceberg, and the increasing number of studies in this field indicate that there are many points to be elucidated in AD pathophysiology. In this review, we aimed to illustrate the current understanding of the underlying pathogenic mechanisms in AD, to evaluate available treatment options with a focus on recently discovered therapeutic agents, and to determine the personal, familial, and economic burdens of the disease, which are frequently neglected issues in AD. Currently available therapies only provide transient solutions and cannot fully cure the disease. However, advances in the understanding of the pathogenic mechanisms of the disease have led to the production of new treatment options, while ongoing drug trials also have had promising results.
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Affiliation(s)
- Pınar Gür Çetinkaya
- Division of Pediatric Allergy and Asthma Unit, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Ümit Murat Şahiner
- Division of Pediatric Allergy and Asthma Unit, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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20
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Phan K, Smith SD. Mycophenolate mofetil and atopic dermatitis: systematic review and meta-analysis. J DERMATOL TREAT 2019; 31:810-814. [PMID: 31294617 DOI: 10.1080/09546634.2019.1642996] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background: For severe cases of atopic dermatitis, systemic or potent agents may be required for control of disease. There have been some reports of treatment efficacy of off-label use of mycophenolate mofetil (MMF) in patients with refractory atopic dermatitis or have developed adverse effects to initial systemic agents.Methods: Electronic searches were performed using six databases from their inception to April 2019. Data were extracted and analyzed according to predefined clinical endpoints.Results: From 140 cases, the mean age was 38.21 ± 22.8 years. There were 52.9% males and 47.1% females. The average number of failed agents was 3.5 ± 1.2. 77.6% reported partial or full remission. Relapses occurred in 8.2% of cases. The average time for initial effects was 6.8 ± 7 weeks. There was a significant reduction in pre to post SCORAD scores by 18 points (p = .0002). More males had complications compared to females. Prolonged duration of treatment ≥1 year was associated with herpes infections.Conclusions: In summary, the current evidence to date is low-quality in nature but is promising regarding the efficacy and safety of MMF for adult and pediatric atopic dermatitis. There should be ongoing monitoring for infections that may develop on long term therapy.
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Affiliation(s)
- Kevin Phan
- Department of Dermatology, Liverpool Hospital, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Saxon D Smith
- Department of Dermatology, Royal North Shore Hospital, St Leonards, Sydney, Australia.,Northern Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia.,The Dermatology and Skin Cancer Centre, Sydney, Australia
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21
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Abstract
GENERAL PURPOSE The purpose of this learning activity is to provide information about the diagnosis and management of atopic dermatitis (AD). TARGET AUDIENCE This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES After completing this continuing education activity, you should be able to:1. Recall the diagnostic process of AD.2. Identify nonpharmacologic therapies for skin care in patients with AD.3. Explain the pharmacologic management of AD. ABSTRACT Atopic dermatitis is a chronic, relapsing, intensely pruritic inflammatory skin disease that affects both children and adults. This article provides an overview of the epidemiology, clinical features, pathophysiology, complications, and specific investigations of atopic dermatitis. The current and novel therapies for the treatment of atopic dermatitis will be discussed.
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22
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Johnson BB, Franco AI, Beck LA, Prezzano JC. Treatment-resistant atopic dermatitis: challenges and solutions. Clin Cosmet Investig Dermatol 2019; 12:181-192. [PMID: 30962700 PMCID: PMC6432884 DOI: 10.2147/ccid.s163814] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Atopic dermatitis (AD) is a common, chronic, relapsing-remitting inflammatory disease that can be challenging to treat. Patients with mild disease are usually managed well with good skin care practices including moisturization and appropriate bathing along with intermittent use of topical therapies such as topical corticosteroids and/or topical calcineurin inhibitors during flares. Patients with frequent flares may benefit from proactive application of topical therapies twice a week to the most troublesome areas. Patients with severe disease often present significant treatment challenges. Systemic therapies are usually required for severe AD but have varying degrees of success and can be associated with side-effect profiles that require counseling and close monitoring. Phototherapy has been shown to have success in treating moderate-to-severe AD, but several factors can limit its utility and efficacy including cost and access. New therapies are in development targeting specific pathways relevant for AD. Dupilumab was the first biologic treatment approved in North America, Europe, and Japan for adults with moderate-to-severe AD. Although this treatment can lead to rapid improvement in the majority of patients, there are inadequate responders. In this review, we discuss the clinical challenges and treatment options for moderate-to-severe refractory AD.
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Affiliation(s)
- Brian B Johnson
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY 14642, USA,
| | - Abigail I Franco
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY 14642, USA,
| | - Lisa A Beck
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY 14642, USA,
| | - James C Prezzano
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY 14642, USA,
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23
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Chiricozzi A, Belloni Fortina A, Galli E, Girolomoni G, Neri I, Ricci G, Romanelli M, Peroni D. Current therapeutic paradigm in pediatric atopic dermatitis: Practical guidance from a national expert panel. Allergol Immunopathol (Madr) 2019; 47:194-206. [PMID: 30268381 DOI: 10.1016/j.aller.2018.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 06/13/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION AND OBJECTIVES Atopic dermatitis (AD) is the most common cutaneous inflammatory disease in both adults and children. Although emerging therapeutic approaches are being investigated for the management of pediatric AD, it still needs to be managed with conventional treatments. This consensus document is aimed at providing an update on general management and therapies of pediatric AD, defining practical recommendations for using both topical and systemic agents. MATERIAL AND METHODS A panel of experts consisting of dermatologists and pediatricians were convened in order to define statements, through a Delphi process, standardizing the management of AD in pediatric subjects in a real-world setting. RESULTS A set of practical recommendations obtaining an at least 75% agreement was presented. CONCLUSIONS This set of practical recommendations represents a simple and fast snapshot on the pediatric use of common anti-AD therapeutics.
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24
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Strategies for Successful Management of Severe Atopic Dermatitis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1-16. [DOI: 10.1016/j.jaip.2018.10.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 12/21/2022]
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25
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Sawangjit R, Dilokthornsakul P, Lloyd-Lavery A, Chua S, Lai NM, Dellavalle R, Chaiyakunapruk N. Systemic treatments for eczema: a network meta-analysis. Hippokratia 2018. [DOI: 10.1002/14651858.cd013206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Ratree Sawangjit
- Faculty of Pharmacy, Mahasarakham University; Department of Clinical Pharmacy; 41/20 Kham Riang Kantharawichai Mahasarakham Thailand 44150
| | - Piyameth Dilokthornsakul
- Naresuan University; Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences; 99 Tha Pho Muang Phitsanulok Thailand 65000
| | - Antonia Lloyd-Lavery
- Oxford University Hospitals NHS Foundation Trust; Department of Dermatology; Churchill Hospital Roosevelt Drive Oxford UK OX3 7LE
| | - Sean Chua
- urong East St21 Blk288A #03-358 Singapore Singapore 601288
| | - Nai Ming Lai
- Taylor's University; School of Medicine; Subang Jaya Malaysia
| | - Robert Dellavalle
- University of Colorado School of Medicine; Denver VA Medical Center 1055 Clermont St. #165 Denver Colorado USA 80220
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26
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Wollenberg A, Barbarot S, Bieber T, Christen-Zaech S, Deleuran M, Fink-Wagner A, Gieler U, Girolomoni G, Lau S, Muraro A, Czarnecka-Operacz M, Schäfer T, Schmid-Grendelmeier P, Simon D, Szalai Z, Szepietowski JC, Taïeb A, Torrelo A, Werfel T, Ring J. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol 2018; 32:850-878. [PMID: 29878606 DOI: 10.1111/jdv.14888] [Citation(s) in RCA: 413] [Impact Index Per Article: 68.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 01/29/2018] [Indexed: 12/17/2022]
Abstract
This guideline was developed as a joint interdisciplinary European project, including physicians from all relevant disciplines as well as patients. It is a consensus-based guideline, taking available evidence from other guidelines, systematic reviews and published studies into account. This second part of the guideline covers antimicrobial therapy, systemic treatment, allergen-specific immunotherapy, complementary medicine, psychosomatic counselling and educational interventions, whereas the first part covers methods, patient perspective, general measures and avoidance strategies, basic emollient treatment and bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy. Management of AE must consider the individual clinical variability of the disease. Systemic immunosuppressive treatment with cyclosporine, methotrexate, azathioprine and mycophenolic acid is established option for severe refractory cases, and widely available. Biologicals targeting the T helper 2 pathway such as dupilumab may be a safe and effective, disease-modifying alternative when available. Oral drugs such as JAK inhibitors and histamine 4 receptor antagonists are in development. Microbial colonization and superinfection may cause disease exacerbation and can require additional antimicrobial treatment. Allergen-specific immunotherapy with aeroallergens may be considered in selected cases. Psychosomatic counselling is recommended especially in stress-induced exacerbations. Therapeutic patient education ('Eczema school') is recommended for children and adult patients. General measures, basic emollient treatment, bathing, dietary intervention, topical anti-inflammatory therapy, phototherapy and antipruritic therapy have been addressed in the first part of the guideline.
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Affiliation(s)
- A Wollenberg
- Department Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany.,Klinik Thalkirchner Straße, Munich, Germany
| | - S Barbarot
- Department of Dermatology, Centre Hospitalier Universitaire CHU Nantes, Nantes, France
| | - T Bieber
- Department of Dermatology and Allergy, Christine Kühne-Center for Allergy Research and Education, University Bonn, Bonn, Germany
| | - S Christen-Zaech
- Pediatric Dermatology Unit, Departments of Dermatology and Pediatrics, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - M Deleuran
- Department Dermatology, Aarhus University Hospital, Aarhus, Denmark
| | - A Fink-Wagner
- European Federation of Allergy and Airways Diseases Patients' Associations (EFA), Global Allergy and Asthma Patient Platform (GAAPP), Konstanz, Germany
| | - U Gieler
- Department of Dermatology, University of Gießen and Marburg GmbH, Gießen, Germany.,Department of Psychosomatics and Psychotherapy, University of Gießen and Marburg GmbH, Gießen, Germany
| | - G Girolomoni
- Department of Medicine, Section of Dermatology, University of Verona, Verona, Italy
| | - S Lau
- Pediatric Pneumology and Immunology, Universitätsmedizin Berlin, Berlin, Germany
| | - A Muraro
- Centro di Specializzazione Regionale per lo Studio e la Cura delle Allergie e delle Intolleranze Alimentari presso l'Azienda Ospedaliera, Università di Padova, Padova, Italy
| | | | - T Schäfer
- Dermatological Practice, Immenstadt, Germany
| | - P Schmid-Grendelmeier
- Allergy Unit, Department of Dermatology, University of Zurich, Zurich, Switzerland.,Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland
| | - D Simon
- Department Dermatology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Z Szalai
- Department of Dermatology, Heim Pál Children's Hospital, Budapest, Hungary
| | - J C Szepietowski
- Department of Dermatology, Venereology and Allergology, Wroclaw Medical University, Wroclaw, Poland
| | - A Taïeb
- Department of Dermatology & Pediatric Dermatology, Hôpital St André, Bordeaux, France
| | - A Torrelo
- Department of Dermatology, Hospital Niño Jesus, Madrid, Spain
| | - T Werfel
- Department Dermatology and Allergy, Hannover Medical School, Hannover, Germany
| | - J Ring
- Christine Kühne-Center for Allergy Research and Education (CK-CARE), Davos, Switzerland.,Department Dermatology and Allergy Biederstein, Technische Universität München, Munich, Germany
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Taieb Y, Baum S, Ben Amitai D, Barzilai A, Greenberger S. The use of methotrexate for treating childhood atopic dermatitis: a multicenter retrospective study. J DERMATOL TREAT 2018; 30:240-244. [PMID: 30109960 DOI: 10.1080/09546634.2018.1508816] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Atopic dermatitis is a chronic inflammatory skin disease. Methotrexate is an off-label systemic agent for treating uncontrolled atopic dermatitis. OBJECTIVE This study assessed the safety and efficacy of methotrexate in pediatric patients with atopic dermatitis. METHODS This multicenter, retrospective study assessed pediatric patients with atopic dermatitis who were treated with methotrexate. RESULTS Medical records of 26 pediatric patients with atopic dermatitis were reviewed. All the patients had Investigator Global Assessment (IGA) scores of 3-4 and had received systemic therapy before receiving methotrexate. In all, 53.85% patients showed clinical improvement at 3 and 6 months after methotrexate initiation. The IGA scores of the patients decreased significantly at 3 months after methotrexate initiation compared with those at baseline; moreover, the IGA scores of the patients at 6 months after methotrexate initiation were lower than those at 3 months after methotrexate initiation. In all, 54% study patients are still undergoing methotrexate treatment. Median satisfaction rate with methotrexate was 7.5/10. However, 10.35% patients developed adverse events, of which only one patient discontinued the treatment. CONCLUSIONS Our results indicate that methotrexate is a tolerable and effective agent for treating refractory childhood atopic dermatitis.
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Affiliation(s)
- Yossi Taieb
- a Dermatology Department , Sheba Medical Center , Ramat Gan , Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Sharon Baum
- a Dermatology Department , Sheba Medical Center , Ramat Gan , Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Dan Ben Amitai
- b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel.,c Dermatology Unit , Schneider Children's Medical Center of Israel , Petah Tikva , Israel
| | - Aviv Barzilai
- a Dermatology Department , Sheba Medical Center , Ramat Gan , Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Shoshana Greenberger
- a Dermatology Department , Sheba Medical Center , Ramat Gan , Israel.,b Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Siegfried EC, Jaworski JC, Mina-Osorio P. A Systematic Scoping Literature Review of Publications Supporting Treatment Guidelines for Pediatric Atopic Dermatitis in Contrast to Clinical Practice Patterns. Dermatol Ther (Heidelb) 2018; 8:349-377. [PMID: 29858763 PMCID: PMC6109028 DOI: 10.1007/s13555-018-0243-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Treatment guidelines endorse a variety of strategies for atopic dermatitis (AD) which may vary from published data and clinical practice patterns. The objective of this review was to quantify the volume of available medical literature supporting pediatric AD treatments and compare these patterns to those recommended by published guidelines and/or clinical practice patterns. METHODS Searches of Embase (2005-2016) and abstracts from selected meetings (2014-2016) related to AD treatment in patients younger than 17 years of age yielded references that were assessed by study design, primary treatment, age groups, and AD severity. RESULTS Published literature partially supports clinical guidelines, with emollients and topical medications being the most investigated. There were disproportionately more publications for topical calcineurin inhibitors (TCI) compared with topical corticosteroids (TCS); however, the search interval may have biased the results toward treatments approved near the beginning of the time frame. In contrast, publications documenting clinical practice patterns reflect greater use of emollients and TCS (over TCI), as well as systemic corticosteroids. Data is relatively limited for long-term and combination treatment, treatment of severe AD, and patients younger than 2 years of age, and completely lacking for systemic corticosteroids. CONCLUSION This scoping review demonstrates that available medical literature largely supports published guidelines for topical therapy; however, clinical practice patterns are less aligned. There is a lack of data for older, more frequently used generic treatments, including oral antihistamines, oral antibiotics, and systemic corticosteroids. Overall, literature is lacking for long-term treatment, treatment for patients younger than 2 years of age, and for systemic treatment for severe disease. FUNDING Regeneron Pharmaceuticals Inc.
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Affiliation(s)
- Elaine C Siegfried
- Saint Louis University and Cardinal Glennon Children's Hospital, St. Louis, MO, USA
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29
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Systemic Treatment for Severe Atopic Dermatitis. Arch Immunol Ther Exp (Warsz) 2018; 67:69-78. [PMID: 30159581 DOI: 10.1007/s00005-018-0521-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 08/10/2018] [Indexed: 02/07/2023]
Abstract
Atopic dermatitis (AD) is a chronic inflammatory, relapsing disease of the skin, characterized by intense pruritus, maculopapular or vesicular erythematous lesions and scaling, sometimes accompanied by oozing, crusts and/or lichenification that has a negative impact on patients' quality of life. Prevalence is higher in children, around 15%, and approximately 5% in adults. Before introducing systemic therapy, it is mandatory to review patients' adherence to the correct use of topical treatments (corticosteroids, calcineurin inhibitors or cresoborole) and/or phototherapy. Ensure that environmental measures are being taken care of, irritant or proven allergic substances are not in use and even if the diagnostic is correct. If all is being done and topical treatment with corticosteroid, emollients and phototherapy have not been sufficient to achieve a good control in AD of adults or children patients, it is time to consider systemic agents. Up to now, most of systemic treatments were based on immunosuppressive therapies, being cyclosporine A, the usually first choice for moderate-to-severe AD. Recently, biologic drugs have been developed and approved for AD, as dupilumab, and a whole new group of drugs is giving much hope for patients to have a better control of the disease with less side effects.
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Dias-Polak D, Bergman R, Avitan-Hersh E. Mycophenolate mofetil therapy in adult patients with recalcitrant atopic dermatitis. J DERMATOL TREAT 2018; 30:49-51. [PMID: 29683760 DOI: 10.1080/09546634.2018.1468068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Patients with severe atopic dermatitis (AD) may require potent immunosuppressive therapy to control their disease. Mycophenolate mofetil (MMF) has been suggested as a safe and effective drug in these cases. OBJECTIVES To investigate effectiveness and tolerability of oral MMF in adult patients with severe recalcitrant AD. METHODS During the years 2010-2017 oral MMF 2-3 g/day was administered to adult patients with severe recalcitrant AD who failed other major systemic drugs, or where other drugs, including cyclosporine (CSA), methotrexate, and azathioprine, were contraindicated. RESULTS Of 9 consecutive adult patients, 4 (44%) responded completely, 2 (22%) had partial response, and 3 (33%) did not respond at all. The MMF therapy was continued for 5-36 months (average 21 months) without major side effects. CONCLUSIONS Oral MMF may be an effective drug in AD. Due to its good safety profile, it may be recommended as a first-line systemic therapy, or successive to CSA in the long term.
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Affiliation(s)
- David Dias-Polak
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel
| | - Reuven Bergman
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel.,b The Bruce Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Emily Avitan-Hersh
- a Department of Dermatology, Rambam Health Care Campus , Technion - Israel Institute of Technology , Haifa , Israel.,b The Bruce Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
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Seegräber M, Srour J, Walter A, Knop M, Wollenberg A. Dupilumab for treatment of atopic dermatitis. Expert Rev Clin Pharmacol 2018; 11:467-474. [DOI: 10.1080/17512433.2018.1449642] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Marlene Seegräber
- Derpartment of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
| | - Jerome Srour
- Derpartment of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
| | - Alexandra Walter
- Derpartment of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
| | - Macarena Knop
- Derpartment of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
| | - Andreas Wollenberg
- Derpartment of Dermatology and Allergy, Ludwig-Maximilian-University, Munich, Germany
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32
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Leis-Dosil V, Prats-Caelles I. Practical Management of Immunosuppressants in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2018. [DOI: 10.1016/j.adengl.2017.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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33
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Leis-Dosil VM, Prats-Caelles I. Practical Management of Immunosuppressants in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2017; 109:24-34. [PMID: 28964393 DOI: 10.1016/j.ad.2017.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 03/24/2017] [Accepted: 05/14/2017] [Indexed: 12/17/2022] Open
Abstract
The treatment of inflammatory and autoimmune diseases is challenging because of their frequency and complexity. Treatment of these diseases is based on the suppression of the patient's immune system using corticosteroids, corticosteroid-sparing immunosuppressive agents, and biologic drugs, making an understanding of the management of immunosuppressive therapy essential. Before an immunosuppressive agent is prescribed, a study must be carried out to identify contraindications, detect latent infections, and determine the most appropriate dose. During treatment, regular monitoring is required to detect adverse effects. The clinician must be familiar with the time lag between start of treatment and onset of the immunosuppressive effect as well as the maximum recommended duration of treatment and cumulative dose for each drug. As dermatologists we are accustomed to using these immunosuppressive agents, but we should have a good knowledge of the guidelines for their use and the monitoring required in each case if we are to reduce variability and avoid potentially serious adverse effects.
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Affiliation(s)
- V M Leis-Dosil
- Sección de Dermatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España.
| | - I Prats-Caelles
- Sección de Dermatología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, España
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Dvorakova V, O'Regan GM, Irvine AD. Methotrexate for Severe Childhood Atopic Dermatitis: Clinical Experience in a Tertiary Center. Pediatr Dermatol 2017; 34:528-534. [PMID: 28730617 DOI: 10.1111/pde.13209] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Atopic dermatitis (AD) affects up to 20% of children. Although the majority of patients are adequately controlled using emollients, topical corticosteroids, topical calcineurin inhibitors, or phototherapy, children with moderate to severe AD may require systemic treatment for control. The objective of the current study was to evaluate the efficacy and safety of methotrexate in children with severe AD attending a tertiary referral center. METHODS A retrospective chart review was undertaken of all children who received methotrexate for severe AD at our tertiary referral center from November 2010 to August 2015. RESULTS Forty-seven children were started on methotrexate for AD during this period. The mean Investigator Global Assessment (IGA) at the 3- to 5-month follow-up improved from 4.25 to 2.8, with further improvement to 1.9 in the patients that continued therapy beyond 10 months. Changes in the Children's Dermatology Life Quality Index (CDLQI) mirrored changes in the IGA, with improvement in the mean CDLQI from 14.4 at the start of the treatment to 7.5 at the 3- to 5-month follow-up. Further improvement in the CDLQI to 6.6 in patients who continued methotrexate beyond 10 months confirmed continued improvement in disease control beyond medium-term therapy. The treatment was well tolerated. CONCLUSIONS Methotrexate appears to be an effective, safe treatment for severe pediatric AD. Its therapeutic effects continue beyond the medium-term treatment period, as reflected by further improvement in IGA and CDLQI scores in patients who continued methotrexate therapy beyond 10 months.
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Affiliation(s)
- Veronika Dvorakova
- Pediatric Dermatology Department, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Grainne M O'Regan
- Pediatric Dermatology Department, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland
| | - Alan D Irvine
- Pediatric Dermatology Department, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,National Children's Research Centre, Our Lady's Children's Hospital, Crumlin, Dublin, Ireland.,Department of Clinical Medicine, Trinity College, Dublin, Ireland
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Huang A, Cho C, Leung DYM, Brar K. Atopic Dermatitis: Early Treatment in Children. CURRENT TREATMENT OPTIONS IN ALLERGY 2017; 4:355-369. [PMID: 29868331 DOI: 10.1007/s40521-017-0140-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Therapeutic regimens for the treatment and long-term management of AD traditionally had a two-fold objective of decreasing skin inflammation and repairing the defective skin barrier. Essential treatments for AD in children should include topical moisturizers for skin hydration and prevention of flares, topical anti-inflammatory medications (e.g. corticosteroids, calcineurin inhibitors, PDE4 inhibitor), allergen/irritant avoidance, and treatment of skin infections. Treatment regimens should be severity-based, and implemented in a stepwise approach tailored to the individual patient. This stepwise approach includes initial use of emollients, gentle skin care, and escalating to more potent anti-inflammatory treatments as the disease severity increases. Currently available systemic medications should be reserved for the presence of recalcitrance to topical therapies due to associated toxicities. We believe that early treatment of AD is not only essential in treating the skin disease, but also in preventing the development of additional atopic diseases, such as food allergy, asthma and allergic rhinitis. The defective skin barrier of AD permits a route of entry for food and environmental allergens, and upon exposure, keratinocytes secrete TSLP, which activates the TH2 pathway. This TH2 differentiation sets off the atopic march and the subsequent diseases that are seen. This review highlights treatment options and strategies in pediatric AD therapy with an emphasis on early therapy. Supporting evidence on the efficacy and safety of each intervention will be discussed.
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Affiliation(s)
- Amy Huang
- Department of Dermatology, State University of New York Downstate Medical Center, Brooklyn, NY
| | - Christine Cho
- Department of Pediatrics, National Jewish Health, Denver, CO
| | | | - Kanwaljit Brar
- Department of Pediatrics, National Jewish Health, Denver, CO
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Chong JH, Koh MJA. Non-topical management of recalcitrant paediatric atopic dermatitis. Arch Dis Child 2017; 102:681-686. [PMID: 28209661 DOI: 10.1136/archdischild-2016-312106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 01/22/2017] [Accepted: 01/24/2017] [Indexed: 01/14/2023]
Abstract
Atopic dermatitis (AD) is a common chronic, pruritic skin disease in children. As the incidence of AD increases, especially in high-income countries, paediatricians may see an increasing number of recalcitrant AD cases in their practice. Although these cases are principally managed by paediatric dermatologists, it is important for paediatricians to be aware of the use and side effects of non-topical treatment like phototherapy and systemic agents as well as the evidence for alternative treatment, which caregivers may ask about. This review presents paediatric evidence for the practical use of phototherapy and certain oral immunosuppressants for paediatric AD including doses, duration of use and monitoring of adverse effects. The use of alternative therapy including traditional medicine, probiotics and the role of nutrition are also discussed. Narrow band ultraviolet B phototherapy is effective in recalcitrant paediatric AD. When phototherapy is ineffective or contraindicated, systemic drugs may be administered cautiously with close surveillance of side effects. The use of azathioprine, ciclosporin, methotrexate and mycophenolate mofetil is generally safe in the short term under close monitoring and can be effective alongside compliance to topical treatment. Alternative complementary treatment is not known to be effective. Holistic management including therapeutic patient education is important. Good quality paediatric studies for non-topical AD treatment are needed for definitive guidelines.
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Affiliation(s)
- Jin Ho Chong
- Dermatology service, KK Women's and Children's Hospital, Singapore.,Department of General Paediatrics, KK Women's and Children's Hospital, Singapore
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Systemic Therapy of Atopic Dermatitis: When, How, for How Long? CURRENT DERMATOLOGY REPORTS 2017. [DOI: 10.1007/s13671-017-0176-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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38
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Abstract
Atopic dermatitis (AD) is a chronic inflammatory skin condition that requires a manifold approach to therapy. The goal of therapy is to restore the function of the epidermal barrier and to reduce skin inflammation. This can be achieved with skin moisturization and topical anti-inflammatory agents, such as topical corticosteroids and calcineurin inhibitors. Furthermore, proactive therapy with twice weekly use of both topical corticosteroids and calcineurin inhibitors in previously affected areas has been found to reduce the time to the next eczematous flare. Adjunctive treatment options include wet wrap therapy, anti-histamines, and vitamin D supplementation. Bacterial colonization, in particular Staphylococcus aureus, can contribute to eczematous flares and overt infection. Use of systemic antibiotics in infected lesions is warranted; however, empiric antibiotics use in uninfected lesions is controversial. Local antiseptic measures (i.e., bleach baths) and topical antimicrobial therapies can be considered in patients with high bacterial colonization. Difficult-to-treat AD is a complex clinical problem that may require re-evaluation of the initial diagnosis of AD, especially if the onset of disease occurs in adulthood. It may also necessitate evaluation for contact, food, and inhaled allergens that may exacerbate the underlying AD. There are a host of systemic therapies that have been successful in patients with difficult-to-treat AD, however, these agents are limited by their side effect profiles. Lastly, with further insight into the pathophysiology of AD, new biological agents have been investigated with promising results.
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Affiliation(s)
- Melanie Chong
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA.
| | - Luz Fonacier
- Rheumatology, Allergy & Immunology, Winthrop University Hospital, 120 Mineola Blvd, Suite 410, Mineola, NY, 11501, USA
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Prescription Treatment Options. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1027:105-120. [DOI: 10.1007/978-3-319-64804-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Niculescu L, Rothenberger C, Pinarci M, Peric J, Alharbi R, Wollenberg A. New Perspectives in the Treatment of Atopic Dermatitis in the Pediatric Population. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2016; 29:189-195. [PMID: 35923062 DOI: 10.1089/ped.2016.0720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Treatment of children diagnosed with atopic dermatitis (AD) is an art. Age-dependent barrier function, skin physiology, body surface:weight ratio, the compliance of patient and caregivers, and legal considerations related to the license status of topical and systemic drugs must be considered. Mild to moderate AD can usually be treated sufficiently with a personalized regimen of emollients and topical anti-inflammatory therapy consisting of topical corticosteroids (TCSs) or topical calcineurin inhibitors. Emollients containing bacterial lysates, tailored wet wrap regimen, and proactive therapy with tacrolimus ointment or some TCSs are new developments in the field. Severe AD may need systemic therapy, but all currently available systemic agents for severe AD are either not licensed for children or not advisable on the long term, or both. Therapeutic patient education based on structured, interactive sessions with patients or caregivers and a multidisciplinary team is highly effective. This publication summarizes the current therapeutic options used in the pediatric AD population.
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Affiliation(s)
- Luana Niculescu
- Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany
| | | | - Melda Pinarci
- Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany
| | - Jelena Peric
- Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany
- Department of Dermatovenerology, Clinical Center of Serbia, Belgrade, Serbia
| | - Rehab Alharbi
- Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany
- Department of Dermatology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Andreas Wollenberg
- Department of Dermatology and Allergy, Ludwig-Maximilian University, Munich, Germany
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Wollenberg A, Oranje A, Deleuran M, Simon D, Szalai Z, Kunz B, Svensson A, Barbarot S, von Kobyletzki L, Taieb A, de Bruin-Weller M, Werfel T, Trzeciak M, Vestergard C, Ring J, Darsow U. ETFAD/EADV Eczema task force 2015 position paper on diagnosis and treatment of atopic dermatitis in adult and paediatric patients. J Eur Acad Dermatol Venereol 2016; 30:729-47. [DOI: 10.1111/jdv.13599] [Citation(s) in RCA: 267] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/10/2015] [Indexed: 12/27/2022]
Affiliation(s)
- A. Wollenberg
- Department of Dermatology and Allergy; Ludwig-Maximilian-University; Munich Germany
| | - A. Oranje
- Department of Dermatology (Pediatric Dermatology and Hair); Dermicis Skin clinic; Alkmaar and Rotterdam The Netherlands
| | - M. Deleuran
- Department of Dermatology; Aarhus University Hospital; Aarhus Denmark
| | - D. Simon
- Department of Dermatology; Inselspital; Bern University Hospital; University of Bern; Bern Switzerland
| | - Z. Szalai
- Heim Pal Childrens Hospital; Budapest Hungary
| | - B. Kunz
- Dermatologikum; Hamburg Germany
| | - A. Svensson
- Department of Dermatology; University Hospital UMAS; Malmö Sweden
| | - S. Barbarot
- Department of Dermatology; University of Nantes; Nantes France
| | | | - A. Taieb
- Service de Dermatologie et Dermatologie Pédiatrique; Centre de référence pour les maladies rares de la peau; INSERM 1035; Université de Bordeaux; Talence France
| | - M. de Bruin-Weller
- Department of Dermatology; University of Utrecht; Utrecht The Netherlands
| | - T. Werfel
- Department of Dermatology; Hautklinik Linden; MHH; Hannover Germany
| | - M. Trzeciak
- Department of Dermatology, Venereology and Allergology; Medical University of Gdansk; Gdansk Poland
| | - C. Vestergard
- Department of Dermatology; Aarhus University Hospital; Aarhus Denmark
| | - J. Ring
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
- Christine Kühne Center for Allergy Research and Education (CK-CARE); Davos Switzerland
| | - U. Darsow
- Department of Dermatology and Allergy Biederstein; Technische Universität München; Munich Germany
- ZAUM - Center of Allergy & Environment; Munich Germany
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43
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Thomas W, Werner A, Frank A, Matthias A, Tilo B, Thomas D, Regina FH, Uwe G, Annice H, Julia K, Alexander K, Alexander N, Katja N, Hagen O, Bernhard P, Martin R, Martin S, Peter SG, Jochen S, Thomas S, Doris S, Margitta W. Leitlinie Neurodermitis [atopisches Ekzem; atopische Dermatitis]. J Dtsch Dermatol Ges 2015; 14:e1-75. [DOI: 10.1111/ddg.12884] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
| | - Aberer Werner
- Österreichische Gesellschaft für Dermatologie und Venerologie
| | - Ahrens Frank
- Gesellschaft für Pädiatrische Allergologie und Umweltmedizin e.V
| | - Augustin Matthias
- Arbeitsgemeinschaft Gesundheitsökonomie und Evidenzbasierte Medizin der Deutschen Dermatologischen Gesellschaft
| | | | - Diepgen Thomas
- Arbeitsgemeinschaft Berufs- und Umweltdermatologie der Deutschen Dermatologischen Gesellschaft
| | - Fölster-Holst Regina
- Arbeitsgemeinschaft Pädiatrische Dermatologie der Deutschen Dermatologischen Gesellschaft
| | | | | | | | - Kapp Alexander
- Deutsche Gesellschaft für Allergologie und Klinische Immunologie
| | - Nast Alexander
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V. (Moderation)
| | - Nemat Katja
- Berufsverband der Kinder- und Jugendärzte e.V
| | - Ott Hagen
- Deutsche Gesellschaft für Kinder- und Jugendmedizin e.V
| | - Przybilla Bernhard
- Arbeitsgemeinschaft Allergologie der Deutschen Dermatologischen Gesellschaft
| | | | | | | | | | | | - Staab Doris
- Arbeitsgemeinschaft Neurodermitisschulung e.V
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Abstract
The approach to children and adults with atopic dermatitis is similar. In both age groups, failure to respond to conventional therapy should prompt evaluation for complicating factors such as secondary infection and secondary ACD. Immunologic, metabolic, genetic, and nutritional disorders should be considered in the differential diagnosis of refractory pediatric atopic dermatitis. Cutaneous T cell lymphoma (CTCL), cutaneous drug reactions, other spongiotic dermatoses, psoriasis, dermatomycosis, and infestations should be considered in the differential of refractory atopic dermatitis in adults. Systemic therapies prescribed to both children and adults with severe atopic dermatitis include oral corticosteroids, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil.
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Affiliation(s)
- Smita Awasthi
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123.
| | - Marti Jill Rothe
- Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032
| | - Lawrence F Eichenfield
- Department of Pediatric and Adolescent Dermatology, Rady Children's Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123
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Abstract
Atopic dermatitis (AD), or eczema, is a chronic inflammatory skin condition characterized by relapsing pruritic, scaly, erythematous papules and plaques frequently associated with superinfection. The lifelong prevalence of AD is over 20 % in affluent countries. When a child with severe AD is not responding to optimized topical therapy including phototherapy, and relevant triggers cannot be identified or avoided, systemic therapy should be considered. If studies show early aggressive intervention can prevent one from advancing along the atopic march, and relevant triggers such as food allergies cannot be either identified or avoided, systemic therapy may also play a prophylactic role. Though the majority of evidence exists in adult populations, four systemic non-specific immunosuppressive or immunomodulatory drugs have demonstrated efficacy in AD and are used in most patients requiring this level of intervention regardless of age: cyclosporine, mycophenolate mofetil, methotrexate, and azathioprine. This article reviews the use of these medications as well as several promising targeted therapies currently in development including dupilumab and apremilast. We briefly cover several other systemic interventions that have been studied in children with atopic dermatitis.
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Affiliation(s)
- Eliza R Notaro
- Dermatology Division, Seattle Children's Hospital, University of Washington School of Medicine, 2480 Birch Ave N #1105, Seattle, WA, 98109, USA.
| | - Robert Sidbury
- Dermatology Division, Seattle Children's Hospital, OC.9.835-Dermatology, 4800 Sand Point Way NE, Seattle, WA, 98105, USA.
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Kim JE, Kim HJ, Lew BL, Lee KH, Hong SP, Jang YH, Park KY, Seo SJ, Bae JM, Choi EH, Suhr KB, Lee SC, Ko HC, Park YL, Son SW, Seo YJ, Lee YW, Cho SH, Park CW, Roh JY. Consensus Guidelines for the Treatment of Atopic Dermatitis in Korea (Part II): Systemic Treatment. Ann Dermatol 2015; 27:578-92. [PMID: 26512172 PMCID: PMC4622892 DOI: 10.5021/ad.2015.27.5.578] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 08/12/2015] [Accepted: 08/16/2015] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Since the treatment guidelines for atopic dermatitis (AD) were issued by the Korean Atopic Dermatitis Association (KADA) work group in 2006, there have been further advances in the systemic treatment of AD. OBJECTIVE We aimed to establish updated evidence- and experience-based systemic treatment guidelines for Korean AD. METHODS We compiled a database of references from relevant systematic reviews and guidelines regarding the systemic management of AD, including antihistamines, antimicrobials, systemic immunomodulators, allergen-specific immunotherapy, phototherapy, adjunctive treatment, and complementary and alternative medicines. Evidence for each statement was graded and classified based on the strength of the recommendation. Thirty-nine council members of KADA participated in the three rounds of votes and expert consensus recommendations were established. RESULTS The use of antihistamines is recommended to relieve pruritus and to prevent exacerbation due to scratching in AD patients. Infection should be controlled as needed and long-term medication should be avoided. For moderate to severe AD patients, concomitant active treatments with systemic immunomodulators are indicated. Cyclosporine is the first choice among systemic immunomodulators and others should be considered as second-line alternatives. Allergen-specific immunotherapy could be effective in AD patients with aeroallergen hypersensitivity. Phototherapy can be useful for moderate to severe AD patients and narrow-band ultraviolet B is the most effective option. Complementary and alternative medicines cannot be recommended for treating AD. CONCLUSION We expect these recommendations to be a reference guide for physicians and AD patients in choosing the appropriate treatment to improve quality of life and decrease unnecessary social medical costs.
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Affiliation(s)
- Jung Eun Kim
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hyun Jeong Kim
- Department of Dermatology, Seoul Medical Center, Seoul, Korea
| | - Bark-Lynn Lew
- Department of Dermatology, Kyung Hee University College of Medicine, Seoul, Korea
| | - Kyung Ho Lee
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Phil Hong
- Department of Dermatology, Dankook University Medical College, Cheonan, Korea
| | - Yong Hyun Jang
- Department of Dermatology, Kyungpook National University School of Medicine, Daegu, Korea
| | - Kui Young Park
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seong Jun Seo
- Department of Dermatology, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jung Min Bae
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eung Ho Choi
- Department of Dermatology, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Ki Beom Suhr
- Department of Dermatology, SA Dermatology Clinic, Daejeon, Korea
| | - Seung Chul Lee
- Department of Dermatology, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun Chang Ko
- Department of Dermatology, Pusan National University School of Medicine, Busan, Korea
| | - Young Lip Park
- Department of Dermatology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang Wook Son
- Department of Dermatology, Korea University College of Medicine, Seoul, Korea
| | - Young Jun Seo
- Department of Dermatology, Chungnam National University College of Medicine, Daejeon, Korea
| | - Yang Won Lee
- Department of Dermatology, Konkuk University School of Medicine, Seoul, Korea
| | - Sang Hyun Cho
- Department of Dermatology, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chun Wook Park
- Department of Dermatology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Joo Young Roh
- Department of Dermatology, Gachon University Gil Medical Center, Incheon, Korea
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47
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Atopic dermatitis: current treatment guidelines. Statement of the experts of the Dermatological Section, Polish Society of Allergology, and the Allergology Section, Polish Society of Dermatology. Postepy Dermatol Alergol 2015; 32:239-49. [PMID: 26366146 PMCID: PMC4565838 DOI: 10.5114/pdia.2015.53319] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 06/30/2015] [Accepted: 06/30/2015] [Indexed: 12/16/2022] Open
Abstract
Atopic dermatitis (AD) is a condition frequently encountered in medical practices across the country. More than 60% of children with AD are at risk to develop allergic rhinitis or asthma (the atopic march). Patients with AD have a unique predisposition to colonization or infection by Staphylococcus aureus. Treatments for AD need to rapidly control symptoms of the disease, improve quality of life and prevent exacerbations. Given the chronic and relapsing nature of the disease, therapies need to encourage good compliance and be well tolerated.
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48
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Abstract
Atopic dermatitis (AD) is a common childhood inflammatory disease that, in a small percentage of cases, can become severe enough to require potent systemic treatment. Many trials have been conducted with systemic agents for the treatment of severe pediatric AD; we review the evidence here. Although corticosteroids are widely used in practice, they are not generally recommended as a systemic treatment option for AD in children. Most patients experience a relatively rapid and robust response to cyclosporine. Treating children with cyclosporine long term is troubling; however, azathioprine, mycophenolate mofetil, and methotrexate are all reasonable alternatives for maintenance therapy in recalcitrant cases. Several additional options are available for the most refractory cases, including interferon-γ, intravenous immunoglobulin, and various biologics. Phototherapy is another modality that can be effective in treating severe AD. Ultimately the choice of agent is individualized. Systemic therapy options are associated with potentially severe adverse effects and require careful monitoring. Nonsystemic approaches toward prevention of flares and long-term control of atopic dermatitis in pediatric patients should be continued in conjunction with systemic therapy. In the future, more targeted systemic treatments hold the potential for effective control of disease with fewer side effects than broadly immunosuppressive agents.
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Affiliation(s)
- Nathaniel A Slater
- Department of Dermatology, School of Medicine, University of North Carolina-Chapel Hill, 410 Market Street, Suite 400 Chapel Hill, NC, 27516
| | - Dean S Morrell
- Department of Dermatology, School of Medicine, University of North Carolina-Chapel Hill, 410 Market Street, Suite 400 Chapel Hill, NC, 27516.
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49
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Nygaard U, Vestergaard C, Deleuran M. Systemic Treatment of Severe Atopic Dermatitis in Children and Adults. CURRENT TREATMENT OPTIONS IN ALLERGY 2014. [DOI: 10.1007/s40521-014-0032-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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50
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