Myth: Because atopic dermatitis is skin-deep, systemic therapy is unnecessary.
Although atopic dermatitis (AD) primarily is known as a skin condition, recent research has indicated that it may be the start of the “atopic march” leading to the development of 1 or more other atopic conditions with multiorgan involvement. In infancy AD can progress to asthma and allergic rhinitis. Adult AD can be accompanied by systemic diseases such as inflammatory bowel disease, nephritic syndrome, and others. There also is a link between impairment of epidermal barrier function and disturbed skin microbiome in patients with AD. Therefore, systemic therapy may be warranted; the question is when should you use systemic therapy?
Most AD patients have mild to moderate disease that responds well to emollients and avoidance of disease triggers and other skin irritants. However, many AD patients experience a more severe disease course that does not respond adequately to topical therapy. For these patients, systemic therapy is a viable treatment option to improve quality of life (QOL), prevent flares, and control skin inflammation and other AD symptoms.
In 2017 an expert panel of the International Eczema Council proposed an algorithm to be used to determine if systemic therapy is warranted in patients with AD. Dermatologists must consider disease severity, impact on QOL, and risks and benefits of systemic therapies. Before starting systemic therapy, the panel recommends the following:
- Consider alternate or concomitant diagnoses
- Avoid triggers
- Optimize topical therapy
- Ensure adequate patient/caregiver education
- Treat coexistent infection
- Assess QOL
- Consider phototherapy
The American Academy of Dermatology established Guidelines of Care for the Management of AD in 2014, which provide recommendations for the most efficacious systemic agents.
Armed with these guidelines, dermatologists can work with patients to determine the most appropriate treatment course for this condition that is more than skin-deep.
Atopic dermatitis is a skin barrier abnormality that causes inflammatory skin disease and an inflammatory disorder triggering abnormal barrier. Whether we choose the outside-in or inside-out approach, it is clear that there is a systemic inflammation associated with skin disease. It is true that children respond well to barrier repair and topical therapy in many settings, as do many adults. However, chronic skin inflammation is not in isolation, triggering mucosal barrier changes allowing for more sensitization to foods and respiratory allergens as well as systemic inflammation in adults. Despite the utility of systemic steroids, the side effects generally outweigh benefit. On the other hand, phototherapy and systemic agents can clear skin and induce remissions and improved QOL. The AAD guidelines were reported before US Food and Drug Administration approval of newer agents such as dupilumab, leaving it up to the dermatologist to find the niche for this first biologic agent for AD.
—Nanette B. Silverberg, MD
Darlenski R, Kazandjieva J, Hristakieva E, et al. Atopic dermatitis as a systemic disease [published online November 22, 2013]. Clin Dermatol . 2014;32:409-413.
Sidbury R, Davis DM, Cohen DE, et al; American Academy of Dermatology. Guidelines of care for the management of atopic dermatitis: section 3. management and treatment with phototherapy and systemic agents [published online May 9, 2014]. J Am Acad Dermatol . 2014;71:327-349.
Simpson EL, Bruin-Weller M, Flohr C, et al. When does atopic dermatitis warrant systemic therapy? recommendations from an expert panel of the International Eczema Council [published online August 10, 2017]. J Am Acad Dermatol . 2017;77:623-633.
Thomas CL, Fernández-Peñas P. The microbiome and atopic eczema: more than skin deep [published online January 28, 2016]. Australas J Dermatol . 2017;58:18-24.