Atopic Dermatitis –

Beyond Topical Therapy

Sarina B. Elmariah, MD, PhD Karol Timmons, RN, MS, CPNP

Instructor in Dermatology, Pediatric Nurse Practitioner
Harvard Medical School; Atopic Dermatitis Center
Director, MGH Itch Clinic, Clinical Coordinator
Massachusetts General Hospital Boston Children's Hospital

Corinna Rea, MD, MPH

Instructor in Pediatrics,
Harvard Medical School;
Director, General Academic Pediatric Fellowship,
Boston Children's Hospital
Faculty Disclosures

▪ Sarina B. Elmariah, MD, PhD

• Consulting fee: Menlo Therapeutics
▪ Corinna Rea, MD, MPH
• None
▪ Karol Timmons, RN, MS, CPNP
• Consulting fee: Pfizer NP Advisory Board

▪ Off label use of medications will be

discussed.

2
Learning Objectives

▪ Plan the appropriate level of treatment by

assessing the burden of disease associated
with AD
▪ Identify for whom and when new and
emerging targeted therapies apply for
patients with AD
▪ Incorporate the principles of shared
decision-making to the treatment selection,
monitoring of disease and treatment
outcomes of patients with AD
3
 Atopic Dermatitis
▪ Chronic inflammatory skin disease characterized
by itchy, dry and inflamed skin of variable
severity that affects children and adults
▪ Relapsing and remitting course
▪ Affects ~5-25% of pediatric population
worldwide, and incidence is increasing
• 11% in pediatric population in US
• Typical onset is before 5 yo, severity improves with
age in many cases but ~ 50% have persistence into
adulthood

Williams H, et al. J Allergy Clin Immun. 1999;103(1):125-138.

Shaw TE, et al. J Invest Dermatol. 2011;131(1):67-73. 4
 Atopic Dermatitis

▪ Co-morbidities:
• Atopic march
AD → allergic rhinitis → asthma
• Food sensitivities (30-80%)
▪ Risk factors
• Family history of atopic triad (70%)
• Filaggrin mutations

Eller E, et al. Allergy. 2009;64(7):1023-1029.

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351.
Rodriguez E, et al. J Allergy Clin Immunol. 2009;123(6):1361-1370. 5
 Clinical Manifestations
▪ Cardinal features include dry skin and severe itch
▪ Phases
• Acute: erythematous papules, vesiculation, crusting
and oozing
• Subacute: pink erythematous papules & plaques,
scaling, and early lichenification
• Chronic: variable erythema, xerosis, lichenification,
fissures

Images from
UpToDate and
Medicine Net 6
Clinical Manifestations

▪ Age affects distribution:

• Infants/toddlers (0-2 yo): acute lesions on
scalp, cheeks, extensor extremities
• Young children to adolescents (2-17 yo):
acute to chronic lesions on flexures (neck,
antecubital, volar, popliteal fossae)
• Adults: may be more localized to eyelids/face,
hands, or become generalized in severe
cases
– Generally spares axillae and groin, although can
contribute to vulvar dermatitis
7
 Clinical Manifestations
Infants Adolescents Adults

8
Images from UpToDate, Medicine Net, NHS, Medscape
 Diagnostic Criteria
▪ The American Academy of Dermatology
recommends
• Essential features:
– Pruritus
– Eczema (acute, subacute, chronic)
– Age appropriate distribution or morphology
– Chronic or relapsing history
• Supportive features:
– Symptom onset in early childhood (typically < 2yo)
– Family history of AD, allergic rhinitis, asthma
– IgE reactivity, xerosis
• Exclusion of other dermatitis triggers
Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351.
9
 Differential Diagnosis
▪ Allergic contact dermatitis
▪ Hypersensitivity reactions and Hyper IgE
syndromes
▪ Tinea
▪ Scabies
▪ Cutaneous T Cell Lymphoma
▪ Viral exanthems
▪ Nutritional deficiencies
▪ Seborrheic dermatitis
▪ Psoriasis

Barrett M, Luu M. Immunol Allergy Clin North Am. 2017;37(1):11-34. 10

 AD Pathophysiology

▪ Complex pathophysiology
• “Outside-in” theory
– Barrier dysfunction leads to immune
dysregulation
• “Inside-out” theory
– Immune dysfunction leads to breakdown
of barrier

Ong PY. Annals of Allergy, Asthma & Immunology. 2018;1:3-4. 11

 12
Illustration from Paller AS, et al. J Allergy Clin Immunol. 2017;140(3):633-643.
 Defective Barrier Function
▪ Structural proteins (e.g. • Increased trans-
Filaggrin (FLG), claudin) epidermal water loss
▪ Cell adhesion molecules and
tight-junction proteins (e.g. • Altered microbial
claudin 1, occludens, colonization
desmogleins)

▪ Proteases inhibitors (e.g.

LETK1 (SPINK5))
▪ Lamellar body assembly
(matrin (TMEM79))
▪ Extracellular
matrix/connective tissue
function (e.g. matrix
metalloproteinases
(ADAMTS))
• Dysfunctional
inflammatory cytokine
release
• Altered nerve structure
and function
Liang Y, et al.,Clin Rev Allergy Immunol. 2016;51(3):315-328.
Dežman K, et al. Int J Immunogenet. 2017;44(5):212-218.
Brandner J, et al. Tissue Barriers. 2015;3(1-2):e974451. 13
 Impaired Innate Immunity

• Increased
▪ Reduced Toll Like susceptibility to
Receptors (TLRs) 2 and colonization/infection
9 expression with different
pathogens

▪ Altered anti-microbrial • Increased exposure

peptides (AMPs) to allergens and
irritants

• Vicious cycle of
barrier disruption

Yu Y, et al. J of Translational Medicine. 2015;13:384.

Kim BE, Leung DYM. Allergy, Asthma & Immunology Research. 2018;10(3):207-215. 14
 Impaired Adaptive Immunity

▪ Increased expression of • Reduced expression

• IL-4, IL-13 epidermal barrier proteins
• IL-22
• IL-31 • Elevations in IgE (IL-4,
IL-13)
• IL-33
• IL-5 • Increased immune cell
trafficking into the skin
▪ Polymorphisms in thymic
stromal lymphopoeitin • Increased pro-
(TSLP) inflammatory cytokine
release
▪ Increased
Phosphodiesterase 4 • Activates itch (e.g. TSLP,
(PDE4) in immune cells IL-4, IL-31)
Roesner LM, et al. Expert Rev Clin Immunol. 2016;12(7):787-796. 15
 Co-Morbidities
▪ Allergic rhinitis ▪ Cardiovascular
▪ Asthma disease
▪ Food allergies ▪ Depression/anxiety/
▪ Keratoconjunctivitis ADHD
▪ Xerosis or ▪ Anemia
ichthyosis vulgaris ▪ Lymphoma/CTCL

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351. 16

 Burden of Disease
▪ Psychosocial impact leads to reduced
quality of life (QoL)
• Poor sleep – 60% to 85% (exacerbation)
• Mood changes – irritability, behavioral
problems
• Memory reduction and poor concentration
• Depression/anxiety
• Social isolation and embarrassment
– Clothing restrictions
– Limitation in sports activities

Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351. 17

 Burden of Disease

▪ Economic impact
• Absences from school or work
• Increased expenses on skin care
products (emollients, medications and
other therapies)
▪ Impact on families
• Poor sleep
• Economic burden
Eichenfield LF, et al. J Am Acad Dermatol. 2014;70(2):338-351. 18
 How to Assess Disease Burden
Clinical Activity Impact on Quality of Life
▪ Distribution ▪ Impact on sleep
▪ Severity ▪ Impact on QoL
▪ Chronicity ▪ Impact on family

Eczema Activity Severity index Sleep: Regensburg

SCORing Atopic Dermatitis Insomnia Scale or Pittsburgh
Investigator Global Sleep Quality Index
Assessment QoL: ItchyQoL, Dermatology
Patient Oriented Eczema Life Quality Index
Measure
Itch NRS
19
Silverberg JI, et al. Annals of Allergy, Asthma & Immunology. 2018;121:340-347.
 Skin Barrier Dysfunction

Dry Skin Inflammation Infection/Colonization Itch

Avoid triggers
Topical
Dilute bleach baths Emollient
Moisturize AT corticosteroids
Topical/oral Wet wrap
LEAST twice daily +/- Topical
antibiotics +/- Antihistamine at
calcineurin inhibitors
night

20
When managing patients with AD, I
recommend the following:

Very infrequent bathing, as bathing

A. dries the skin

Figuring out what food or other allergen

B. is triggering the AD

Developing a skincare plan independently

C. and giving it to the patient to follow

Working with the patient to develop a

D. realistic skincare plan that they will use

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 Moisturizer

▪ Skin barrier dysfunction leads to water loss and

dry skin -> moisturizer should be first line
therapy
▪ Patients should moisturize at least TWO times
per day, especially after bathing and
handwashing
▪ Helps with itch, consistent use can lead to less
need for corticosteroids

Grimalt R, et al. Dermatology. 2007;214(1):61-67.

Msika P, et al. Pediatr Dermatol. 2008;25(6):606-612.
Gelmetti C, et al. Pediatr Dermatol. 2012;29:714-718. 22
Moisturizer

• Most water, evaporation can

Lotion be problematic, also
preservatives/solubilizers

• Some water, can be

Cream irritating due to
preservatives/ solubilizers

• No water, sometimes not

Ointment well tolerated

Should use fragrance-free products

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 Bathing
▪ We recommend daily bath/shower, 5-10
minutes, lukewarm water
• Limited evidence to support certain frequency or
modality
• Shared decision-making important
▪ Pat dry (rubbing=“scratching in disguise”)
▪ Limited use of non-soap cleansers
▪ Important to apply emollient within 3
minutes of bathing (soak-and-seal)
▪ Bath additives not shown to be helpful
Gutman AB, et al. Arch Dermatol. 2005;141(12):1556-1559.
Loden M, et al. Br J Dermatol. 2004;150(6):1142-1147.
Mochizuki H, et al. Pediatr Dermatol. 2009;26(2):223-226.
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 Dilute Bleach Baths

▪ Sodium hypochlorite has disinfectant and

antimicrobial properties
▪ Reduces need for systemic antibiotics
▪ Reduced S aureus burden and
decreased disease severity
▪ Add 1/4 to 1/2 cup of (6%) household
bleach to a standard bath tub full of water
▪ Dramatic clinical improvement
Huang JT, et al. Pediatrics. 2009;123(5):e808-e814.
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 Wet Wraps

• Re-hydrates and calms skin

• Can be combined with topical steroids
• Recovers epidermal barrier function
• Reduced redness and skin inflammation
• Diminished itching
• Provides continuous moisturization
• Provides protective barrier
• Improves sleep

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González-López G, et al. Br J Dermatol. 2017;177(3):688.
 Wet Wraps

▪ Take wet pajamas right out of washer

(damp)
▪ After bath apply creams, etc.
▪ Put on wet PJ’s covered by dry PJ’s
▪ Hands/Feet:
➢Wet socks or gloves
➢Cover with dry socks or gloves
▪ May put dry PJs/socks in dryer

Lio PA, et al. J Allergy Clin Immunol Pract. 2014;2(4):361-369; quiz 370.
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 Irritant Avoidance
▪ Fragranced products
▪ Soaps, detergents, astringents
▪ Low humidity, heat
▪ Abrasive fabrics, tight clothing
▪ Stress
▪ Testing/elimination of allergens controversial
• Generally only recommended to test for food
allergens if patient not responding to treatment
and/or reliable history of immediate reaction
after ingestion
• Some studies show AD improvement with
reduction of aeroallergens, but evidence mixed
Schneider L, et al. J Allergy Clin Immunol. 2013;131(2):295-299.
Nassif A, et al. Arch Dermatol. 1994;130(11):1402-1407.
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 Antihistamines

▪ Commonly used for control of pruritus, but

evidence lacking that they are helpful
▪ Studies suggest good skincare and topical
medications more effective for controlling itch
▪ Sedating antihistamines can be helpful at night
▪ Patients with concurrent allergic symptoms
may also find some benefit

Klein PA, Clark RA. Arch Dermatol. 1999;135(12):1522-1525.

Simons FE. J Allergy Clin Immunol. 2001;107(4):703-706.
29
Schneider L, et al. J Allergy Clin Immunol. 2013;131(2):295-299.
 Topical Corticosteroids
▪ Potency 1-7
• 7=low potency
• 1=high potency
▪ Ointments generally more effective than creams
unless patients have a strong preference
▪ Long-term should use least potent effective
corticosteroid, but may be appropriate to use
higher potency for short courses
▪ Can apply 1-2x per day for flares, usually up to 2
weeks
▪ Good evidence for using preventively in patients
with moderate/severe disease (1-2x/wk)
Thomas KS, et al. BMJ. 2002;324:768.
Schmitt J, et al. Br J Dermatol. 2011;164(2):415-428.
Hanifin J, et al. Br J Dermatol. 2002;147(3):528-537.
30
 Topical Corticosteroids
▪ Incidence of reported side effects low
▪ Use caution on face and in skin folds (thin skin)
▪ Possible side effects include:
• Skin atrophy
• Purpura
• Telangiectasia
• Striae
• Acneiform/rosacea-like eruptions
• Potential for hypothalamic-pituitary-adrenal axis
suppression->use particular caution in children
Callen J, et al. Br J Dermatol. 2007;156(2):203-221.
Hengge UR, et al. J Am Acad Dermatol. 2006;54(1):1-15. 31
 Topical Corticosteroids

▪ Should monitor for adverse effects

▪ Patients/families often nervous about side
effects, which can lead to underuse (“steroid
phobia”)
• Shared decision-making and education can
be helpful to allay fears and avoid underuse

Charman CR, et al. Br J Dermatol. 2000;142(5):931-936.

Beattie PE, Lewis-Jones MS. Clin Exp Dermatol. 2003;28(5):549-553.
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 Topical Calcineurin Inhibitors

▪ Two available:
• Tacrolimus ointment (0.03% and 0.1%)
• Pimecrolimus cream (1%)
▪ Can be used for acute and chronic
treatment for adults and children, 2x daily
▪ Do not cause skin atrophy, so are useful
steroid-sparing agents, especially at sites
with thin skin

Ashcroft DM, et al. BMJ. 2005;330(7490):516.

Chen SL, et al. J Dermatolog Treat. 2010;21(3):144-156.
33
 Topical Calcineurin Inhibitors
▪ Tacrolimus 0.03% ointment and
pimecrolimus cream approved for children 2
and older, but AAD guidelines suggest off-
label use in children <2
▪ Can cause skin burning on application-
>usually improves after a week of use
▪ Can use proactively 2-3x/week on areas
that flare
▪ Should discuss black-box warning
Eichenfield LF, et al. J Am Acad Dermatol. 2014;71(1):116-132.
Paller AS, et al. Pediatrics. 2008;122(6):e1210-1218.
34
Breneman D, et al. J Am Acad Dermatol. 2008;58(6):990-999.
 Topical PDE4 inhibitor
▪ Crisaborole ointment
• Non-steroidal, boron-based PDE4 inhibitor
ointment approved for mild to moderate AD in
adults and children ≥2 years
▪ Reduces inflammation and itching
▪ Maintains skin barrier
▪ No serious treatment-related adverse effects
reported
• Some patients report stinging and pain on
application
• No atrophy, telangiectasia, hypopigmentation
Paller AS, et al. J Am Acad Dermatol. 2016;75(3):494-503.e4. 35
Tom WL, et al. Pediatr Dermatol. 2016;33(2):150-159.
Case 1
▪ 13-year-old male with multiple food allergies, asthma,
and patches of mild eczema on his hands, arms and
legs presents to his pediatrician
▪ He has been prescribed hydrocortisone 2.5% ointment
in the past, but does not use it because his parents are
worried about side effects
▪ Upon questioning, he admits he does not apply the
vaseline that has been recommended to him because
he finds it too greasy. He also likes to take 20 minute
showers in hot water.

36
The most appropriate next step for this
patient is:

He should use the vaseline and hydrocortisone

A. 2.5% ointment as previously recommended

The potency of his topical corticosteroid ointment

B. should be increased

He should focus on food allergy avoidance, as he is

C. likely eating something that is triggering his eczema

A shared decision-making approach should be used

to develop a plan around bathing, emollient and
D. topical corticosteroid use that the patient and family
are more likely to follow
37
 Shared Decision-Making
▪ Many families want a “cure”
• Educate about chronic relapsing course of
disease and natural history
• Good skincare is essential, not just medications
▪ Regimens can be complex
• Adherence often poor
• Important to engage in shared decision-making
– What can they actually do day-to-day?
– Which products will they really use?
• Also important to give written instructions

Ring L, et al. J Dermatolog Treat. 2007;18(4):209-218.

Tan J, et al. Br J Dermatol. 2016;175(5):1045-1048.
Krejci-Manwaring J, et al. J Am Acad Dermatol. 2007;56(2):211-216. 38
 When to Consider Systemic Therapy

▪ Consider alternate diagnoses or

aggravating factors → limit triggers
• Patient and family education is key!
▪ Optimize topical therapies and emollients
▪ Eliminate or reduce infectious triggers
▪ After the above interventions, re-evaluate
disease severity and QoL
• Moderate to severe disease activity
• Impaired QoL

Simpson, et al. J Am Acad Dermatol. 2017;77:623-633. 39

 Options for Systemic AD Therapy
▪ Use in conjunction with topical therapies and
emollients, trigger avoidance, etc.
▪ Options to consider:
• Phototherapy
• Oral steroids (acute exacerbation only!)
• Non-steroidal immunosuppression
• Biologics
• Many new drugs in the pipeline!
▪ Issues to consider: age, transportation options,
medical comorbidities, and personal
preference and risk profile
Ring L, et al. J Dermatolog Treat. 2007;18(4):209-218.
Tan J, et al. Br J Dermatol. 2016;175(5):1045-1048.
Krejci-Manwaring J, et al. J Am Acad Dermatol. 2007;56(2):211-216. 40
Phototherapy
▪ Second line after failure of topical therapy
▪ Most useful in adults, older adolescents
▪ Multiple wavelengths and devices
• Narrowband UVB – most common
• Broadband UVB
• UVA – highest risk of skin cancer

41
 Phototherapy
▪ Light modality determined by availability, cost,
medication history, history of skin cancer
▪ Dosing and frequency of treatments determined by
skin type and disease severity
• Typically requires 2-3x weekly for months
• Improvement observed after 15-25 treatments
• Location
– Office based
– Home units available
▪ Potential risks/SEs: burning, erythema,
photosensitivity, non-melanoma skin cancer, cataracts

Pérez-Ferriols A, et al. Actas Dermosifiliogr. 2015;106(5):387. 42

 Systemic Immunomodulators
▪ Indicated in adults and children
• After failure to respond to topicals and phototherapy
• Negative physical and emotional impact
▪ General themes
• Systemic steroids should only be used in acute or
very severe flares as a bridge to non-steroidal
therapy
• Attempt control for 4-6 months, then consider
tapering off to re-assess response to topicals
• Risk of infection, malignancy, lab monitoring

Simpson EL, et al. J Am Acad Dermatol. 2017;77(4):623. 43

 Dupilumab: Injectable Biologic Therapy
▪ Fully human monoclonal antibody against the
interleukin-4 receptor - alpha subunit of IL-4 and IL-13
receptors
▪ Target: 600 mg SC x 1 dose, then 300 mg every 2 weeks
▪ Consider weekly dosing if only moderate improvement
with Q2Wk dosing
▪ Improvement seen within 2-12 weeks
▪ Approved for adults 18 and over
▪ Ongoing clinical trials for adolescents and children
▪ No lab monitoring required
▪ Major SEs: conjunctivitis (~10%), injection site
reaction, HSV recurrence

Beck LA, et al. N Engl J Med. 2014;371(2):130-139.

Dupilumab (Dupixent) [package insert]. Tarrytown, NY, Bridgewater, NJ: Regeneron Pharmaceuticals, Inc., Sanofi-Aventis U.S. LLC; 44
2017.
 Phase III Dupilumab Trial Results
▪ Both dose regimens of dupilumab showed clinically
meaningful improvement and statistical significance vs.
placebo in:
• AD symptoms (including itch/pruritus and sleep)
• Health-related quality of life
• Symptoms of anxiety/depression as measured by
DLQI
▪ Most AEs were mild or moderate
• Injection site reactions and conjunctivitis were more
frequent with dupilumab compared to control
• Fewer skin infections in dupilumab group

Simpson EL, et al. N Engl J Med. 2016;375:2335-2348. 45

 Long-term management of mod-to-severe AD
with dupilumab

▪ Randomized, double-blind, placebo-controlled, Phase 3

study over 1 year
• SQ dupilumab 300 mg qw, dupilumab 300 mg q2w, or
placebo
• All received concomitant topical CS +/- TCIs
▪ Both dose regimens of dupilumab showed clinical
improvement and statistical significance vs. placebo
▪ Most AEs were mild or moderate
• Injection site reactions and conjunctivitis were more
frequent with dupilumab

Blauvelt A, et al. Lancet. 2017;389(10086):2287-2303. 46

 Dupilumab - Conjunctivitis
▪ Symptoms
• Redness of the conjunctiva bilaterally
• Limbal hyperemia
• Tearing
• Pathogenesis of conjunctivitis-not understood
• Onset wide range (20 to 389 days)
• More severe AD at baseline
– Higher baseline disease severity
– Longer duration of disease
– Prior history of conjunctivitis
– Most cases were mild or moderate
▪ Treatment
• Ocular steroids
• Ocular antibiotics
• Ocular nonsteroidal anti-inflammatories
Wollenberg A, et al. J Allergy Clin Immunol Pract. 2018;6(5):1778-1780.e1.
Treister AD, Kraff-Cooper C, Lio P. JAMA Dermatology. 2018;154(10):1208-1211. 47
 Cyclosporine
▪ Target: 100 to 300 mg daily (Peds 3-6 mg/kg/day)
– Higher doses early improve acute control, typically
2-6 weeks
– Lab monitoring
▪ SEs: infection, nephrotoxicity, hypertension,
headache, tremor, gingival hyperplasia,
hypertrichosis, increased risk of cutaneous
and hematologic malignancies
▪ FDA recommends limiting consecutive CSA
therapy to 12 months

Gooderham M, et al. J Cutan Med Surg. 2017;21(1):31. 48

 Methotrexate
▪ Target: 10-25 mg weekly (Peds 0.2-0.7
mg/kg/wk)
– Improvement within 6-12 weeks
– Oral or intramuscular
– Lab monitoring
– Liver biopsy after cumulative dose reaches 4 g
▪ SEs: nausea, GI upset, transaminitis,
infection, hair loss, pulmonary fibrosis,
stomatitis, increased risk of hematologic
malignancies; long-term hepatoxicity
Roekevisch E, et al. J Allergy Clin Immunol. 2018;141(2):825. 49
 Azathioprine

▪ Target: 1-3mg/kg/d (Peds 1-4 mg/kg/d)

– Dosing may be influenced by Thiopurine
methyl transferase (TPMT) activity level
– Improvement within 8-12 weeks
– Lab monitoring
▪ SEs: nausea, vomiting, diarrhea, GI
upset, transaminitis, infection,
headache, leukopenia

Roekevisch E, et al. J Allergy Clin Immunol. 2018;141(2):825. 50

 Mycophenolate Mofetil
▪ Target: 1000-3000 mg daily (Peds 30-50
mg/kg/d)
– Dosing may be influenced by Thiopurine methyl
transferase (TPMT) activity level
– Improvement within 6-12 weeks
– Lab monitoring
▪ SEs: nausea, vomiting, diarrhea, GI upset,
viral or bacterial infection, hematologic
suppression (anemia, leukopenia,
thrombocytopenia), hematologic malignancy

Thijs JL, et al. J Dermatolog Treat. 2017;28(3):242. 51

Case 2
▪ A 37-year-old woman
with severe eczema,
failed multiple topical
therapies, nb-UVB
phototherapy and
antihistamines to help
with sleep.

▪ Past medical history: food and seasonal allergies, gastritis

▪ Labs: High serum levels of Immunoglobulin E (IgE).
▪ PE: Eczematous plaques on hands, neck, and arms;
Focal areas of skin atrophy.

52
Case 2

▪ Shared decision-making:
• Clinical considerations
– Severity of skin lesions
– Severity of pruritus
– Lack of control with topicals, phototherapy and
anti-histamines
• Quality of life: poor sleep
• Comorbidities: food and seasonal allergies,
gastritis
• What matters to the patient?
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The most appropriate next step to gain
acute control for this patient is:

A. Azathioprine

B. Dupilumab

C. Omalizumab

D. Systemic corticosteroids

54
The most appropriate next step to gain
chronic control for this patient is:

A. Azathioprine

B. Dupilumab

C. Omalizumab

D. Systemic corticosteroids

55
 Emerging drugs for AD
▪ Anti-cytokine drugs ▪ JAK inhibitors
• Topical
• Anti-IL13
• Oral
• Anti-IL12/23
• Anti-17A ▪ Aryl hydrocarbon
receptor agonist
• Anti-IL22
• Anti-IL31R ▪ PDE4 inhibitors
• Anti-IL33
• Anti-TSLP ▪ Microbiome modulators
• Anti-IL5
▪ NK1 receptor inhibitors

Thijs JL, et al. J Dermatolog Treat. 2017;28(3):242. 56

Summary

▪ Patient education and lifestyle modification is

key!
▪ Shared decision making leads to better
outcomes
• Consider severity, quality of life and patient
preferences to guide therapy
▪ Systemic therapy for AD should be considered
with moderate to severe disease and when AD
symptoms impact QoL
▪ Many options for systemic therapy and the list
is growing!

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Q&A
Thank You