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Update on systemic therapies for atopic dermatitis

Denby, Kristopher S.; Beck, Lisa A.

Current Opinion in Allergy and Clinical Immunology: August 2012 - Volume 12 - Issue 4 - p 421–426
doi: 10.1097/ACI.0b013e3283551da5
PHARMACOTHERAPY AND EVIDENCE BASED MEDICINE: Edited by David A. Khan and Enrico Compalati

Purpose of review Although many atopic dermatitis patients can be treated satisfactorily with topical medications and systemic anti-itch approaches, a smaller subset require more aggressive systemic therapies. Familiarity with the latest literature on the benefits and risks of these treatments will enable the clinician and patient to select the most appropriate therapy based on the patient's lifestyle, assessments of risks and comorbidities.

Recent findings Additional data have come to light altering the risk and benefit ratio of certain systemic atopic dermatitis therapies. In 2011, we saw several head-to-head, randomized controlled trials of established systemic medications for the treatment of atopic dermatitis. A few new systemic atopic dermatitis treatments have highlighted how targeted therapies may inform us about disease pathogenesis.

Summary In light of the risk of hepatosplenic T-cell lymphomas, a greater degree of caution is warranted in the use of azathioprine. NBUVB, mycophenolate, and methotrexate remain the reasonable first-line systemic treatment options for atopic dermatitis. A brief run-in with high-dose cyclosporine to clear atopic dermatitis followed by maintenance with low-dose cyclosporine or cellcept – both of which have better risk and benefit ratios is a reasonable approach. Interferon gamma and intravenous immunoglobulin, although expensive, are potential options, and possibly most ideal for atopic dermatitis patients plagued by significant viral skin infections such as eczema herpeticum. A better understanding of the immunopathogenesis of atopic dermatitis will come with the exploration of novel targeted therapies.

Department of Dermatology, University of Rochester Medical Center, Rochester, New York, USA

Correspondence to Lisa A. Beck, MD, Department of Dermatology, University of Rochester, 601 Elmwood Avenue, Box 697, Rochester, NY 14642, USA. Tel: +1 585 275 7546; fax: +1 585 276 2330; e-mail: Lisa_Beck@URMC.ROCHESTER.EDU

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