Atopic Dermatitis

Determine environmental triggers that may be associated with atopic dermatitis

• Genetics

• Infection

• Environmental allergens

• Food

• Hot and extremely cold climates

• Dry weather leading to skin dryness

• Exposure to cigarette smoke

Select an appropriate non-pharmacological treatment regimen for a patient with atopic dermatitis

• Application of moisturizers

  • Occlusive moisturizers (ex. Lanolin, mineral oil based, waxes) - BEST choice for AD

    • Provide an oily layer on the skin’s surface, prevents water loss and protects from irritants

  • Humectants

    • Increase water holding capacity (trap water from environment) 

    • BUT have stinging effect on atopic skin, slightly less beneficial moisturizer 

  • Emollients (fatty acids, cholesterol, ceramides)

    • Smooth out the surface of the skin by filling spaces with droplets of oil

    • Least effective as moisturizers

• Lukewarm baths

• Use of non-soap cleansers at neutral-low pH (avoid high pH), hypoallergenic soaps, and fragrance free

• Wet wrap therapy 

• Avoid synthetic materials like polyester, harsh fabrics like wool → stick to cotton material

Select an appropriate first or second-line pharmacological treatment regimen for a patient with atopic dermatitis.

• First line - Topical corticosteroids

• Second line - Topical calcineurin inhibitors

• Adjunctive/supportive: used when no response or as bridging

  • UV phototherapy (not same as sunlight)

  • Oral antihistamines

  • Systemic corticosteroids (reserved for no response to topicals)

  • MTX or cyclosporine  (reserved for no response to topicals)

Pharm Treatments

Treatment	Uses	Adverse Effects	Additional Notes
Topical Corticosteroid (1st line)	Standard of Care Treatment QD or BID application Low potency for sensitive areas: face, groin, eye area Medium potency for other parts High potency for short term severe exacerbations/flare ups (small areas) Maintenance therapy: low potency steroids used intermittently When control is achieved, there are the options: Stop topical corticosteroids, use only moisturizers Apply only 1-2 times a week if frequent flare ups occur Use low potency daily for lichenified skin in adults after short term treatment with high potency (1-2 weeks)	Topical: Skin atropy, acne, contact dermatitis, hypertrichosis, follucilitis, hypopigmentation, striae, telangiectasis Systemic: HPA axis suppression, Cushing syndrome(rare), cataracts, glaucoma Systemic rxn more likely with potent steroids + long term use of mid potency agents Chronic Use: Can lead to loss of treatment effect Drug holiday: Switch to non-steroid alternative if pt had initial response and worsens while on long term use of corticosteroid therapy Taper down use when lesions improve Don’t use high potency long term	Ointment form: Greasy, not as preferred Most occlusive, most potent Low: Hydrocortisone Mild: Desonide Moderate: Triamcinolone Momentasone Potent: Bethamethasone Clobetasol Fluocinonide
Calcineurin Inhibitors (2nd line)	Tacrolimus 0.03% (Protopic) ointment: Approved for SHORT TERM USE (6 weeks) Mod-severe atopic dermatitis in 2 years and up Tacrolimus 0.1% (Protopic ointment): Mod-severe atopic dermatitis in 16 years and up Pimecrlimus (Elidel) 1% cream: Mild-moderate atopic dermatitis in 2 years and up Perferred b/c lipophilic characteristics and preferential distribution to skin over systemic effects	Topical discomfort (burning sensation) Local skin carcinogenesis (boxed warning) Skin protection highly recommended Sunscreen SPF 30+ Systemic effects: immunosuppression	Use as second line therapy b/c risk of skin carcinogenesis Can be beneficial for patients with significant SE with topical corticosteroids or lack of treatment effect More effective for eyes/sensitive areas  Maintenance therapy 1-2 times a week may be used after use of topical corticosteroids
Adjunctive Treatments
UV Phototherapy	Can be effective as adjunctive (Like Psoriasis UV) Can be steroid sparing Can be used for acute flare ups, maintenance therapy  May assist in reducing bacterial infections associated with AD	Photoaging Photosensitive eruptions Skin cancer
Methotrexate (systemic)	Efficacy: effective for refractory severe atopic dermatitis Dosing is still weekly, 5-30mg PO/SQ	Fatigue Alopecia LFT increases Suppression of blood counts  Decreases folic acid (take supplemental folic acid 1mg PO daily) Leucovorin can also be used, but has potential to decrease MTX efficacy if same day administration GI upset: folic acid can help Pregnancy: X
Cyclosporine (Gengraf)	Efficacy: used to induce remission and maintenance therapy in severe disease Limit to at most 12-week therapy	Nephrotoxic, CBC, HTN, electrolyte imbalances: hypomagnesemia and hyperkalemia, hypertriglyceridemia, skin cancer	Get baseline labs LFTs, Scr, CBC, electrolytes DONT USE WITH MTX
JAK Inhibitors:	Mod-severe atopic dermatitis Orals Abrocitinib (Cibinqo) Upadacitinid (Rinvoq) Topical: Ruxolitinib (Opzelura) 1.5% cream Up to 20% BSA Persistent mod dermatitis	Immunosuppressive, cancer risk, thrombosis risk May be associated