Aggressive systemic therapy may allow greater long-term atopic dermatitis control

Key Points

"Until we can aggressively control the pruritus, topical therapy alone is ineffective in some patients," he tells Dermatology Times. "Sometimes it doesn't matter what you apply topically, the patient will scratch right through it and continue to irritate the skin. This is when the topical medicine alone isn't enough."

Systemic therapy is a good place to begin for these patients, yet it's often underutilized, Dr. Jackson says.

Systemic therapy regimen

When topical moisturizing barrier repair mechanism techniques and topical steroids aren't enough, Dr. Jackson moves toward systemic therapies.

"When it's severe - meaning 30 percent body surface area is affected, or beyond what topical therapy can adequately treat - you need to be aggressive because you're never going to get the AD under control with topical therapy, even if it's the initial presentation," he says.

His preferred systemic option is ultraviolet light or narrowband UV light. Secondly, to gain short-term control for a month or less, he uses systemic corticosteroids. If treatment is needed longer than that, he tends to prefer cyclosporine for six to 12 months. If that doesn't work, or if the patient doesn't tolerate it well, Dr. Jackson moves on to mycophenolate mofetil and azathioprine. Occasionally, he will use methotrexate, he says.

Not for everyone

Some patients are better candidates than others for systemic therapies. Successful outcomes of the treatment depend on several factors.

"We need to look at whether the patient has an underlying illness or health history, a history of malignancy or chronic infections, what other medicines they are taking, or other comorbid conditions," Dr. Jackson says. "Any of these situations will obviously make systemic therapy potentially more difficult."

Some patients are concerned about the side effects of the systemic treatment. Depending on what medicines are used, some people can experience gastrointestinal or renal side effects, while others can have irritation or potential toxicity to the liver. While the side effects don't occur in everyone, they do make patients hesitant to take that route when the topical therapies don't cause any major systemic problems, Dr. Jackson notes.

"If you take on a potentially higher-risk profile for systemic therapy, many times you also take on a significantly better potential for improvement," Dr. Jackson says. "I would use aggressive systemic therapy when we're unable to achieve topical control of the patient's AD or are unable to achieve benefit from appropriate topical therapy. I would also use it if involvement is too widespread for the realistic use of topical therapy alone - essentially, if it's beyond what someone would do topically twice a day based on the body surface area."

But systemic therapy is not equally the regimen of choice for adults and children. Because of the side effects and potential for high-risk profiles in children, as well as parents who are typically very concerned, systemic therapy is not often the first choice for moderate to severe AD in this population, according to Dr. Jackson.