Atopic Dermatitis Management- MPR

Atopic Dermatitis Management

ATOPIC DERMATITIS MANAGEMENT
Therapy		Strength	Dosage form	Dosing/frequency	Recommendations
NONPHARMACOLOGIC
Topical moisturizers	Emollients (glycol and glyceryl stearate, soy sterols)	—	crm, oint, gel, lotion, oil	Liberal and frequent reapplication. Apply soon after bathing to improve skin hydration.	• Mild AD: main primary treatment. • Moderate to severe AD: incorporated into regimen.
	Occlusives (petrolatum, dimethicone, mineral oil)
	Humectants (glycerol, lactic acid, urea)
Prescription emollient devices	Palmitoylethanolamide-, glycyrrhetinic acid-, or other hydrolipid-containing preparations	—	crm	2–3 times daily.	• Adjunct to treatment and maintenance. • More costly than topical moisturizers but not superior.
Bathing	Water	—	—	Once daily for 5–10mins (warm water). Apply moisturizer immediately after bathing. Severely inflamed skin: up to 20mins; apply topical anti-inflammatory therapies (TCS) immediately after without towel drying.	• Use of nonsoap-based surfactants and synthetic detergents (syndets) are often recommended. • Limit use of neutral-to-low pH, hypoallergenic, and fragrance-free nonsoap cleansers. • Limited data on the addition of oils, emollients, and other related additives to bath water, and the use of acidic spring water (balneo-therapy) and water-softening devices; not recommended.
Wet-wrap therapy	Topical agent covered by wetted first layer (tubular bandage, gauze, cotton suit) and dry second layer	—	—	Up to 24hrs at a time for up to 2wks.	• For significant flares and/or recalcitrant disease. • Use with or without TCS for moderate to severe AD (caution with medium to higher potency TCS).¹
Phototherapy	UVB	Narrowband (309–312nm)	—	Administer to affected areas 2–5 times weekly	• Last-line therapy for non-immunocompromised patients with topical treatment failure.
PHARMACOLOGIC²
Topical Corticosteroids³
Very high potency	augmented betamethasone dipropionate (oint)	0.05%	crm, oint, lotion, foam, soln, gel	Treatment: apply twice daily until lesions improve, for up to 2–4wks at a time; for high potency TCS, may apply once daily. Use 0.5g for an area of 2 adult palms. Maintenance: apply 1–2 times weekly for frequent, repeated flares at same site.	• First-line pharmacologic therapy for mild to moderate AD if uncontrolled by moisturizers or irritant avoidance. • Use concomitantly with moisturizers. • Use least potent TCS that is effective. • Lower potency TCS should be used on the face and skin folds and medium to high potency TCS on the body. • Monitor cutaneous side-effects during long-term, potent steroid use. Routine monitoring of systemic effects is not recommended.
	clobetasol propionate	0.05%
	diflorasone diacetate (oint)	0.05%
	halobetasol propionate	0.05%
High potency	amcinonide	0.1%
	augmented betamethasone dipropionate (crm)	0.05%
	betamethasone dipropionate	0.05%
	desoximetasone	0.25%
	desoximetasone (gel)	0.05%
	diflorasone diacetate (crm)	0.05%
	fluocinonide	0.05%
	halcinonide	0.1%
	mometasone furoate (oint)	0.1%
	triamcinolone acetonide	0.5%
Medium potency	betamethasone valerate	0.1%
	clocortolone pivalate	0.1%
	desoximetasone (crm)	0.05%
	fluocinolone acetonide	0.025%
	flurandrenolide	0.05%
	fluticasone propionate	0.05%, 0.005%
	mometasone furoate (crm)	0.1%
	triamcinolone acetonide	0.1%
Lower-medium potency	hydrocortisone butyrate	0.1%
	hydrocortisone probutate	0.1%
	hydrocortisone valerate	0.2%
	prednicarbate	0.1%
Low potency	alclometasone dipropionate	0.05%
	desonide	0.05%
	fluocinolone acetonide	0.01%
Lowest potency	hydrocortisone acetate	0.5–1%
Lowest potency	hydrocortisone base	0.25–1%
Phosphodiesterase 4 (PDE4) Inhibitor
crisaborole	Eucrisa	2%	oint	Mild to moderate: ≥3mos: apply a thin layer to affected areas twice daily; may consider reducing to once daily after clinical effect is achieved.	• First-line treatment
Topical Calcineurin Inhibitors
tacrolimus	Protopic	0.03%, 0.1%	oint	Moderate to severe: ≥2yrs⁴: apply a thin layer to affected areas twice daily. 2–15yrs: use 0.03% strength. ≥16yrs: use 0.03% or 0.1% strength. May use 2–3 times weekly as maintenance therapy to prevent recurrent flares.	• Second-line therapy for short-term and non-continuous chronic treatment of AD in non-immunocompromised patients with inadequate response to topical prescription therapies or when they are not advisable. • Preferred for sensitive areas (eg, face, skin folds). • Not recommended during active infections of lesions. • May be combined with TCS sequentially or concomitantly. • Long term safety has not been established due to association with skin malignancies and lymphoma; avoid continuous long-term use in any age group.
pimecrolimus	Elidel	1%	crm	Mild to moderate: ≥2yrs⁴: apply a thin layer to affected areas twice daily. May use 2–3 times weekly as maintenance therapy to prevent recurrent flares.
Interleukin-4 Receptor Alpha Antagonist
dupilumab	Dupixent	100mg/0.67mL, 200mg/1.14mL, 300mg/2mL	SC inj	Moderate to severe: 6mos–5yrs (5–<15kg): 200mg every 4wks; (15–<30kg): 300mg every 4wks. 6–17yrs (15–<30kg): initially 600mg (two 300mg inj at different sites) followed by 300mg every 4wks; (30–<60kg): initially 400mg (two 200mg inj at different sites) followed by 200mg every other week; (≥60kg): initially 600mg followed by 300mg every other week. ≥18yrs: initially 600mg followed by 300mg every other week.	• Reserved for patients with inadequate response to topical prescription therapies or when they are not advisable. • May use with or without TCS. • Topical calcineurin inhibitors may also be used, but should be reserved only for problem areas (eg, face, neck, intertriginous and genital areas).
tralokinumab-ldrm	Adbry	150mg/mL	SC inj	Moderate to severe: ≥18yrs: initially 600mg (four 150mg inj), followed by 300mg (two 150mg inj) every other week. After 16wks, may consider 300mg every 4wks for patients weighing <100kg who achieve clear or almost clear skin.
Janus Kinase Inhibitor⁵
abrocitinib	Cibinqo	50mg, 100mg, 200mg	tabs	Moderate to severe: ≥12yrs:100mg once daily; may increase to max 200mg once daily if inadequate response after 12wks.	• Reserved for refractory patients with inadequate response to other systemic therapies, including biologics, or when they are not advisable. • May use with or without TCS. • Not recommended for use with biologics, other JAK inhibitors, or potent immunosuppressants (eg, azathioprine, cyclosporine).
ruxolitinib	Opzelura	1.5%	crm	Mild to moderate: ≥12yrs: apply a thin layer to the affected areas (up to 20% BSA) twice daily; max 60g per week or 100g per 2wks. Reevaluate if no improvement within 8wks.	• For short-term and non-continuous chronic treatment of AD in non-immunocompromised patients with inadequate response to topical prescription therapies or when they are not advisable. • Not recommended during active infections, and for use with biologics, other JAK inhibitors, or potent immunosuppressants (eg, azathioprine, cyclosporine).
upadacitinib	Rinvoq	15mg, 30mg, 45mg	ext-rel tabs	Moderate to severe: ≥12yrs (≥40kg): initially 15mg once daily; if inadequate response, consider increasing to 30mg once daily. Elderly (≥65yrs), severe renal impairment (CrCl <30mL/min), or concomitant strong CYP3A4 inhibitors: 15mg once daily.	• Reserved for refractory patients with inadequate response to other systemic therapies, including biologics, or when they are not advisable. • Not recommended for use with biologics, other JAK inhibitors, or potent immunosuppressants (eg, azathioprine, cyclosporine).
NOTES
Key: AD = atopic dermatitis; BSA = body surface area; crm = cream; JAK = Janus kinase; MACE = major adverse cardiovascular events; oint = ointment; soln = solution; UVB = ultraviolet B; TCS = topical corticosteroid ¹ Increased absorption of mid- to higher-potency TCS applied under the wraps may cause hypothalamic-pituitary-adrenal axis suppression. ² Systemic immunosuppressants (eg, methotrexate, mycophenylate mofetil, azathioprine) have been recommended for severe AD in patients with topical treatment failure. ³ See Topical Steroid Potencies chart for more drug information. ⁴ For children aged <2yrs with mild to severe disease, off-label use of tacrolimus 0.03% or pimecrolimus 1% can be recommended. ⁵ Increased risk of serious infections, all-cause mortality, malignancies, MACE, and thrombosis in patients treated with JAK inhibitors for inflammatory conditions. Not an inclusive list of medications and/or official indications. Please see drug monograph at www.eMPR.com and/or contact company for full drug labeling.
REFERENCES
Eichenfield LF, Tom WL, Berger TG, et al. Guidelines of care for the management of atopic dermatitis. American Academy of Dermatology, Inc. Published: May 07, 2014. http://dx.doi.org/10.1016/j.jaad.2014.03.023 Fleming P, Yang YB, Lynde C, O’Neill B, Lee KO. Diagnosis and management of atopic dermatitis for primary care providers. J Am Board Fam Med. 2020; 33 (4); 626-635. (Rev. 6/2023)

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