Management Of Atopic Dermatitis in Adults with Phototherapy and Systemic Therapies

Publication Date: November 7, 2023
Last Updated: November 10, 2023

Summary of Recommendations

Phototherapy

For adults with AD, we conditionally recommend phototherapy. (C, L)
Remarks: Most current literature reports on the efficacy and safety of narrow band UVB. Wherever possible, use a light source that minimizes the potential for harm under the supervision of a qualified clinician.
620

Biologics

For adults with moderate to severe AD, we recommend dupilumab. (S, M)
620
For adults with moderate to severe AD, we recommend tralokinumab. (S, M)
620

JAK inhibitors

For adults with moderate to severe AD, we recommend upadacitinib. (S, M)
Remarks: Upadacitinib is approved by the FDA in patients with AD who have failed other systemic therapies (pills or injections, including biologics) or when use of those therapies is inadvisable.
620
For adults with moderate to severe AD, we recommend abrocitinib. (S, M)
Remarks: Abrocitinib is approved by the FDA in patients with AD who have failed other systemic therapies (pills or injections, including biologics) or when use of those therapies is inadvisable.
620
For adults with moderate to severe AD, we recommend baricitinib. (S, M)
Remark: Baricitinib is not approved by the FDA for use in AD.
620

Antimetabolite

For adults with moderate to severe AD, we conditionally recommend methotrexate with proper monitoring. (C, L)
Remarks: Comorbidities or drug interactions that may exacerbate toxicity make this intervention inappropriate for select patients. The FDA has not approved methotrexate for use in AD.
620

Immunosuppressants

For adults with AD, we conditionally recommend against systemic corticosteroids. (C, L)
Remarks: Their use should be reserved exclusively for acute, severe exacerbations and as a short-term bridge therapy to other systemic, corticosteroid-sparing therapy.
620
For adults with refractory moderate to severe AD, we conditionally recommend mycophenolate mofetil with proper monitoring. (C, VL)
Remarks: Mycophenolate mofetil is not approved by the FDA for use in AD. Comorbidities or drug interactions that may exacerbate toxicity make this intervention inappropriate for select patients.
620
For adults with refractory moderate to severe AD, we conditionally recommend TPMT-dosed azathioprine with proper monitoring. (C, L)
Remarks: Comorbidities or drug interactions that may exacerbate toxicity make this intervention inappropriate for select patients.
620
For adults with refractory moderate to severe AD, we conditionally recommend limited-term use of cyclosporine with proper monitoring. (C, L)
Remarks: Evidence suggests an initial dose of 3 mg/kg/d to 5 mg/kg/d is effective. The FDA has not approved cyclosporine for use in AD§. The FDA has approved limited-term use (up to 1 y) in psoriasis. Comorbidities or drug interactions that may exacerbate toxicity make this intervention inappropriate for select patients.
620

Medication dosing table for use in adults

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Medication Dose Notes
Dupilumab (Dupixent) 600 mg then 300 mg SC every 2 wk Pediatric and adolescent dosing will differ. Please see the product package insert for details.
Tralokinumab (Adbry) 600 mg then 300 mg SC every 2 wk Dose reduction to 300 mg every 4 weeks may be considered after 16 weeks if an adequate response is achieved.
Upadacitinib (Rinvoq) 15 or 30 mg PO daily It is recommended to start at 15 mg daily and increase if needed.
Abrocitinib (Cibinqo) 100 or 200 mg PO daily It is recommended to start at 100 mg daily and increase if needed.
Baricitinib (Olumiant) 2 or 4 mg PO daily Off-label in the US; approved for use for AD in Europe.
Methotrexate 10-25 mg PO or SC weekly Once control is achieved, the dose may be lowered to the lowest possible effective dose.
Azathioprine 2.5-5 mg/kg PO daily Thiopurine methyltransferase genotype or enzyme activity should be checked before treatment initiation and the dose lowered, or the medication not started, depending on the results.
Cyclosporine 3 to 5 mg/kg PO daily It is suggested to start at the higher end of the dosing range and decrease the dose once control is achieved. Use is generally limited to 1 year. Prescribers should be aware of whether the modified or nonmodified form of cyclosporine is being dispensed as this can alter bioavailability, efficacy, and safety.
Mycophenolate mofetil Up to 3000 mg PO daily, divided BID For mycophenolate sodium/acid, 360 mg is equivalent to 500 mg of mycophenolate mofetil.

Adults with atopic dermatitis

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Recommendation Grading

Abbreviations

  • AAD: American Academy Of Dermatology
  • AD: Atopic Dermatitis
  • JAK: Janus Kinase
  • QOL: Quality Of Life

Disclaimer

Overview

Title

Management Of Atopic Dermatitis in Adults With Phototherapy And Systemic Therapies

Authoring Organization

Publication Month/Year

November 7, 2023

Last Updated Month/Year

November 10, 2023

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

To provide evidence-based recommendations on the use of phototherapy and systemic therapies for AD in adults. For most people with atopic dermatitis (AD), emollients and prescription topical therapies are sufficient to achieve AD control. In contrast, people with more severe or widespread AD, people with substantially impaired quality of life (QOL), and individuals whose AD is refractory to optimized topical therapy may consider the use of phototherapy or systemic therapies to improve disease control and QOL.1 Systemic therapies considered in these guidelines include oral medications

Target Patient Population

Adult patients with atopic dermatitis (eczema)

Target Provider Population

Dermatologists, allergists/immunologists, primary care providers, and other clinicians caring for adult patients with atopic dermatitis

Inclusion Criteria

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

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D003876 - Dermatitis, Atopic

Keywords

eczema, atopic dermatitis, phototherapy, Tralokinumab, Dupilumab

Source Citation

Dawn M.R. Davis, Aaron M. Drucker, Ali Alikhan, Lionel Bercovitch, David E. Cohen, Jennifer M. Darr, Lawrence F. Eichenfield, Lindsy Frazer-Green, Amy S. Paller, Kathryn Schwarzenberger, Jonathan I. Silverberg, Anne Marie Singh, Peggy A. Wu, Robert Sidbury,
Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies, Journal of the American Academy of Dermatology, 2023, ISSN 0190-9622, https://doi.org/10.1016/j.jaad.2023.08.102