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Chu DK, Chu AWL, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, Gomez-Escobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O'Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L. Topical treatments for atopic dermatitis (eczema): Systematic review and network meta-analysis of randomized trials. J Allergy Clin Immunol 2023; 152:1493-1519. [PMID: 37678572 DOI: 10.1016/j.jaci.2023.08.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/24/2023] [Accepted: 08/31/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects. OBJECTIVE We sought to systematically synthesize the benefits and harms of AD prescription topical treatments. METHODS For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s). RESULTS The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus. CONCLUSIONS For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.
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Key Words
- Atopic dermatitis (eczema)
- disease severity
- induction of remission and maintenance of remission (reactive or proactive therapy)
- network meta-analysis (comparative effects)
- patient-important outcomes (eczema severity, intensity, itch, sleep, quality of life, flares or flare-ups or exacerbations)
- topical Janus kinase (JAK) inhibitors (ruxolitinib, delgocitinib)
- topical calcineurin inhibitors (pimecrolimus, tacrolimus)
- topical corticosteroids (steroids)
- topical phosphodiesterase-4 (PDE-4) inhibitors (crisaborole, difamilast, lotamilast, roflumilast)
- topical treatments (therapy)
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Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Canada.
| | - Alexandro W L Chu
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Daniel G Rayner
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Gordon H Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Juan José Yepes-Nuñez
- Universidad de Los Andes, Bogotá, Colombia; Fundacion Santa Fe de Bogotá University, Bogotá, Colombia
| | | | | | - Juan Pablo Díaz Martinez
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | | | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Department of Anesthesia, McMaster University, Hamilton, Canada
| | - Melanie M Wong
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Renata Ceccacci
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Irene X Zhao
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - John Basmaji
- Department of Medicine, Western University, London, Canada
| | - Margaret MacDonald
- Department of Medicine, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Xiajing Chu
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada
| | - Nazmul Islam
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Public Health, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Ya Gao
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; Evidence in Allergy Group, McMaster University, Hamilton, Canada; Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Qatar
| | - Ariel Izcovich
- Servicio de Clínica Médica, Hospital Aleman, Buenos Aires, Argentina
| | | | - Mark Boguniewicz
- Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Anna De Benedetto
- Department of Dermatology, University of Rochester Medical Center, Rochester, NY
| | - Korey Capozza
- Global Parents for Eczema Research, Santa Barbara, Calif
| | - Lina Chen
- Evidence in Allergy Group, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada
| | | | | | - Matthew Greenhawt
- Division of Pediatric Allergy and Clinical Immunology, National Jewish Health, Denver, Colo; Section of Allergy and Immunology, Children's Hospital Colorado, Aurora, Colo
| | - Joey Huynh
- Sepulveda VA Medical Center, North Hills, Calif
| | - Jennifer LeBovidge
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Peter A Lio
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, Ill; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | | | | | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics, Keck School of Medicine of USC, Los Angeles, Calif
| | - Jonathan I Silverberg
- Department of Dermatology, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathan M Spergel
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa; Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, Pa
| | | | - Julie Wang
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Lynda Schneider
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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