When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council

• Published in: Journal of the American Academy of Dermatology 2017-10, Vol.77 (4), p.623-633
• Main Authors: Simpson, Eric L., Bruin-Weller, Marjolein, Flohr, Carsten, Ardern-Jones, Michael R., Barbarot, Sebastien, Deleuran, Mette, Bieber, Thomas, Vestergaard, Christian, Brown, Sara J., Cork, Michael J., Drucker, Aaron M., Eichenfield, Lawrence F., Foelster-Holst, Regina, Guttman-Yassky, Emma, Nosbaum, Audrey, Reynolds, Nick J., Silverberg, Jonathan I., Schmitt, Jochen, Seyger, Marieke M.B., Spuls, Phyllis I., Stalder, Jean-Francois, Su, John C., Takaoka, Roberto, Traidl-Hoffmann, Claudia, Thyssen, Jacob P., van der Schaft, Jorien, Wollenberg, Andreas, Irvine, Alan D., Paller, Amy S.
• Format: Article
• Language: English
• Subjects: Administration, Cutaneous; Administration, Oral; atopic dermatitis; azathioprine; biologic; Biological Products - therapeutic use; Clinical Decision-Making; consensus statement; cyclosporine; Dermatitis, Atopic - diagnosis; Dermatitis, Atopic - drug therapy; Dermatitis, Atopic - therapy; Dermatologic Agents - administration & dosage; eczema; Humans; Immunosuppressive Agents - administration & dosage; Immunosuppressive Agents - therapeutic use; Injections; methotrexate; Patient Education as Topic; Phototherapy; Quality of Life; Severity of Illness Index; systemic therapy
• ISSN: 0190-9622; 1097-6787
• DOI: 10.1016/j.jaad.2017.06.042

Although most patients with atopic dermatitis (AD) are effectively managed with topical medication, a significant minority require systemic therapy. Guidelines for decision making about advancement to systemic therapy are lacking. To guide those considering use of systemic therapy in AD and provide a framework for evaluation before making this therapeutic decision with the patient. A subgroup of the International Eczema Council determined aspects to consider before prescribing systemic therapy. Topics were assigned to expert reviewers who performed a topic-specific literature review, referred to guidelines when available, and provided interpretation and expert opinion. We recommend a systematic and holistic approach to assess patients with severe signs and symptoms of AD and impact on quality of life before systemic therapy. Steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy. Our work is a consensus statement, not a systematic review. The decision to start systemic medication should include assessment of severity and quality of life while considering the individual's general health status, psychologic needs, and personal attitudes toward systemic therapies.