Management Of Atopic Dermatitis: Management And Treatment With Phototherapy And Systemic Agents

Publication Date: August 1, 2014

Recommendations

PHOTOTHERAPY

Phototherapy is a second-line treatment, after failure of first-line treatment (emollients, topical steroids, and topical calcineurin inhibitors). (B)
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Phototherapy can be used as maintenance therapy in patients with chronic disease. (B)
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Phototherapy treatment of all forms should be under the guidance and ongoing supervision of a physician knowledgeable in phototherapy techniques. (B)
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The light modality chosen should be guided by factors such as availability, cost, patient skin type, skin cancer history, and patient use of photosensitizing medications. (B)
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The dosing and scheduling of light should be based on minimal erythema dose and/or Fitzpatrick skin type. (B)
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Home phototherapy under the direction of a physician may be considered for patients who are unable to receive phototherapy in an office setting. (C)
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SYSTEMIC AGENTS

Systemic immunomodulatory agents are indicated for the subset of adult and pediatric patients in whom optimized topical regimens and/or phototherapy do not adequately control the signs and symptoms of disease. ()
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Systemic immunomodulatory agents are indicated when the patient’s skin disease has significant negative physical, emotional, or social impact. ()
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All immunomodulatory agents should be adjusted to the minimal effective dose once response is attained and sustained. Adjunctive therapies should be continued to use the lowest dose and duration of systemic agent possible. ()
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Insufficient data exist to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication. ()
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Treatment decisions should be based on each individual patient’s AD status (current and historical), comorbidities, and preferences. ()
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Cyclosporine is effective and recommended as a treatment option for patients with AD refractory to conventional topical treatment. (B)
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Azathioprine is recommended as a systemic agent for the treatment of refractory AD. (B)
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Methotrexate is recommended as a systemic agent for the treatment of refractory AD. Folate supplementation is recommended during treatment with methotrexate. (B)
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Mycophenolate mofetil may be considered as an alternative, variably effective therapy for refractory AD. (C)
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Interferon gamma is moderately and variably effective and may be considered as an alternative therapy for refractory AD in adults and children who have not responded to, or have contraindications to the use of, other systemic therapies or phototherapy. (B)
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Systemic steroids should be avoided if possible for the treatment of AD. Their use should be exclusively reserved for acute, severe exacerbations and as a short-term bridge therapy to other systemic, steroid-sparing therapy. (B)
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ANTIMICROBIALS

Systemic antibiotics

  • None, if noninfected AD
(B)
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  • For infected AD
(A)
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  • Concurrent topical steroid treatment during oral antibiotic course
(C)
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The use of systemic antibiotics in the treatment of noninfected atopic dermatitis is not recommended. (B)
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Systemic antibiotics are appropriate and can be recommended for use in patients with clinical evidence of bacterial infections in addition to standard and appropriate treatments for atopic dermatitis disease itself (which may include the concurrent use of topical corticosteroids). ()
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Systemic antiviral agents should be used for the treatment of eczema herpeticum. (C)
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ANTIHISTAMINES

There is insufficient evidence to recommend the general use of antihistamines as part of the treatment of atopic dermatitis. ()
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Short-term, intermittent use of sedating antihistamines may be beneficial in the setting of sleep loss secondary to itch, but should not be substituted for management of atopic dermatitis with topical therapies. (C)
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Nonsedating antihistamines are not recommended as a routine treatment for atopic dermatitis in the absence of urticaria or other atopic conditions such as rhinoconjunctivitis. (A)
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Recommendation Grading

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Overview

Title

Management Of Atopic Dermatitis: Management And Treatment With Phototherapy And Systemic Agents

Authoring Organization

Publication Month/Year

August 1, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Management, Treatment

Diseases/Conditions (MeSH)

D003876 - Dermatitis, Atopic

Keywords

eczema, atopic dermatitis, phototherapy