Atopic dermatitis: From guidelines to practice

This week during the annual meeting of the American Academy of Dermatology in San Diego, Robert Sidbury, M.D., addressed developments in atopic dermatitis treatments since the publication of treatment guidelines in 2014.

“This is an extraordinary time in the world of atopic dermatitis. We’ve had no new molecules for 17 years and then two in the last year,” said Dr. Sidbury who is of the University of Washington School of Medicine in Seattle.

The U.S. Food and Drug Administration approved the novel topical PDE-4 inhibitor crisaborole for mild-to-moderate atopic dermatitis in December 2016, and the IL4/13 inhibitor dupilumab for moderate-to-severe disease roughly 3 months later, in March 2017.

Dr. Sidbury was co-chair of the work group that developed the 2014 AAD guidelines for the management of atopic dermatitis specific to treatment with phototherapy and systemic agents. 

In October 2017, the International Eczema Council issued a consensus statement in the Journal of the American Academy of Dermatology addressing when atopic dermatitis warrants systemic therapy.

The International Eczema Council states that dupilumab and other systemic medications “should include assessment of severity and quality of life while considering the individual's general health status, psychologic needs, and personal attitudes toward systemic therapies.”

The group provided an algorithm in their article to help clinicians decide when systemic immunomodulatory therapy is warranted. Topical therapy should be optimized before considering systemic medications, and patients who don’t respond need to be evaluated for exacerbating factors including cutaneous infections or alternate diagnoses such as allergic contact dermatitis," the statement says.

Once a decision to use systemic therapy is reached, it’s still not entirely clear how dupilumab fits in with older systemic options, Dr Sidbury said.

“Is it so different and so much better that it's immediately the first systemic we reach for? Or, is it one that we would use after the patient has failed cyclosporine or methotrexate or one of the others? A lot of times, it's not even up to us, because it's the insurance companies who say, ‘Sorry, you can't have the dupilumab,’ even if it's maybe the provider's first choice,” he said.

The optimal role of the novel topical agent crisaborole in mild-to-moderate atopic dermatitis also deserves more research and expert consideration.

Disclosures

Dr. Sidbury reported disclosures related to Galderma USA, Pfizer Inc., Regeneron Pharmaceuticals, Inc., Roche Laboratories, and Scioderm.

References

Robert Sidbury MD, MPH.  “Translating Evidence into Practice: Atopic Dermatitis.” American Academy of Dermatology 2018 Annual Meeting, San Diego, Calif. Feb. 17, 2018. 9:00-11:00 am.

Robert Sidbury, MD, Dawn M. Davis, MD, David E. Cohen, MD, et al. “Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents.” Journal of the American Academy of Dermatology. August 2014. DOI:10.1016/j.jaad.2014.03.030

Eric L. Simpson, MD, MCR, Marjolein Bruin-Weller, MD, PhD, Carsten Flohr, MD, PhD, MSc, et al. “When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council.” Journal of the American Academy of Dermatology. October 2017. DOI:10.1016/j.jaad.2017.06.042.