Recommendations for systemic therapy in eczema

New recommendations from the International Eczema Council aim to address a question that has gone largely unanswered:  When should dermatologists and others prescribe systemic therapy to treat atopic dermatitis?

“We are entering a revolution in systemic therapy of atopic dermatitis,” says article author Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology, Rady Children's Hospital, San Diego. “It is incumbent on us to make sure the right patients are selected to receive them, to ensure the most successful outcomes.”

It’s not so much a question about whether systemic therapies can be safe and effective for atopic dermatitis treatment. Reviews and guidelines have suggested they can be. Rather, few have published research looking at when a patient is a good candidate for the therapy, according to the paper.

Adding clarity to when it’s best to start therapy is important, because while most atopic dermatitis patients manage the condition with topical therapies, a “significant minority” require systemic medications, according to the paper.

The gold standard therapy for most mild-to-moderate atopic dermatitis patients includes optimally using emollients, avoiding irritants and triggers and using topical antiinflammatory therapies. Phototherapy is also a viable option for many of these patients.

Moderate-to-severe pediatric and adult patients who don’t adequately respond to topical therapy or for whom phototherapy isn’t a good option, need access to systemic therapy options. Yet, doctors’ and patients’ decisions to start systemic therapy isn’t an easy one, given risks associated with immunosuppressants, the authors write.

RECOMMENDATIONS FROM THE INTERNATIONAL ECZEMA COUNCIL

To provide clinicians with guidelines for when it’s best to consider adult or pediatric eczema patients as systemic therapy candidates, a large group of experts from the International Eczema Council (IEC) got together to conduct and interpret literature reviews and available guidelines.

“Make sure that you are comfortable that the patient has moderate to severe refractory atopic dermatitis: consider cutaneous lymphoma, allergic contact dermatitis (which can be an alternative [diagnosis], but more commonly an exacerbator of atopic dermatitis), or other conditions as warranted by history and physical findings and prior response to treatment,” he says.

Make sure that the patient has gone through optimized topical therapy. In other words, have they used prescribed topicals, managed cutaneous infections and avoided triggers? Has phototherapy been considered? And has there been appropriate patient/caregiver/family education about disease management?

And assess disease impact.

“Ask if the disease has impacted quality of life, home life, school and work, interpersonal relationships,” Dr. Eichenfield says. “It’s worth knowing this …. It establishes a baseline to assess improvement if systemic therapy is utilized. And it opens up a discussion of risks and benefits of systemic therapy, engaging the patient in the decision-making process.”

In general, the panel recommends that dermatologists and others use a systematic and holistic approach to assess patients with severe atopic dermatitis and how the disease impacts quality of life, before they start systemic therapy. The decision to start systemic therapy should take into account patients’ general health quality, psychologic needs and attitudes toward system options, they conclude.

SYSTEMIC THERAPY

The recommended steps are important, according to Dr. Eichenfield. A thorough analysis may, in fact, suggest a patient doesn’t need to transition to systemic therapy.

“I have had the experience of patients referred for severe atopic dermatitis, with tremendously high body surface area disease, who had never utilized an adequate quantity of mid-strength topical corticosteroids, due to a mixture of medication phobia and the patient not understanding how topical corticosteroids could be used appropriately and safely,” he says. “After education and appropriate use of a prescribed quantity of topical corticosteroids over several weeks (in much larger quantity over two weeks than had been used over months and months), the disease ‘broke’ and maintenance with only intermittent topical corticosteriods was adequate for excellent disease control.”

Another scenario, according to Dr. Eichenfield, is one where allergic contact dermatitis was a big disease driver, though it had not been suspected. 

“Identification of relevant allergens and avoidance totally changed the course of the disease and allowed relatively simple, intermittent topical therapies to keep the atopic dermatitis controlled,” he says.

A potential limitation of the work, according to the authors, is it is a consensus statement; not a systematic review.

DISCLOSURES

Dr. Eichenfield has served as a consultant and/or investigator for Anacor/Pfizer, Galderma, Genentech, Lilly, Regeneron/Sanofi, and Valeant.

REFERENCE

Simpson EL, Bruin-Weller M, Flohr C, Ardern-Jones MR, et al. “When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council,” JAAD. Aug. 10, 2017. DOI: 10.1016/j.jaad.2017.06.042.