Management of severe refractory atopic dermatitis (eczema)

Severe atopic dermatitis - Widespread eczematous papules and plaques are present in this adult with severe atopic dermatitis.


● Severe atopic dermatitis remains a difficult condition to treat. Before initiating second-line treatments for atopic dermatitis, several factors should be addressed:
• Assure that the prescribed treatment regimen is being followed and maximize the use of conventional therapies.
• Intensify efforts to remove exposure to any suspected exacerbating factors.
• Treat secondary infections.
• Confirm that the diagnosis of atopic dermatitis is correct.

● Patients with severe, refractory atopic dermatitis can benefit from phototherapy or systemic immunomodulatory drugs. The use of phototherapy and systemic immunosuppressive agents should be reserved for severe disease that has been refractory to conventional therapy.

● For most adult patients with severe atopic dermatitis that has been refractory to topical therapy, we suggest treating with phototherapy (Grade 2B). For patients with chronic disease, we suggest treatment with narrow band UVB. For patients with acute exacerbations, we suggest treatment with UVA1 (Grade 2B).

● For adult patients in whom phototherapy is not an option or is ineffective, we suggest treatment with cyclosporine or methotrexate (Grade 2C). These agents have been shown to be safe and efficacious, but have different side effect profiles that may influence decisions for individual patients (eg, those with hypertension). Patients should be monitored carefully for adverse effects. Alternative systemic immunosuppressive therapies include mycophenolate mofetil or azathioprine.

● For children with severe refractory atopic dermatitis, we suggest treatment with cyclosporine (Grade 2C). Alternative treatments for these children include phototherapy, azathioprine, or mycophenolate mofetil.

● Systemic glucocorticoids should not be used for the chronic management of atopic dermatitis.

● The use of biologic therapies may be considered on an individual basis after other therapies have been tried and failed. The most promising of the biologic therapies are infliximab, omalizumab, and rituximab. Further studies are necessary before any of these agents can be routinely recommended.

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