Published Online: October 29, 2013
In many patients with moderate-to-severe atopic dermatitis (AD) disease activity requires systemic treatment to achieve adequate disease control. Various immunomodulating therapies are currently being used in patients with AD who do not respond to topical treatments and/or UV-therapy, including glucocorticosteroids, cyclosporin A (CsA), methotrexate (MTX), azathioprine (AZA), interferon-y (IFN), intravenous immunoglobulin (IVIG), mycophenolate mofetil (MMF), and Traditional Chinese Herbal Medicine (TCHM).
In a systematic review published recently in The Journal of Allergy and Clinical Immunology (JACI), Roekevisch et al. critically appraise the evidence of 34 trials on 12 different systemic treatments for AD. All fully published randomly controlled trials reporting on systemic treatments for patients with moderate-to-severe AD were eligible. In accordance with the HOME (Harmonising Outcome Measures for Eczema) core outcome domains for AD-trials, outcomes concerning clinical signs, symptoms, health-related quality of life, and course of AD were extracted as efficacy outcomes. To compare safety data, the incidence rates (%) per patient per week for adverse event (AE), serious adverse event (SAE), and withdrawals due to AE or SAE were calculated.
Thirty-four trials were included, totaling 1,653 patients. CsA efficaciously improves clinical signs of AD in children and adults and is recommended as first line treatment for short-term use. AZA is recommended for short-term induction treatment and long-term treatment up to 24 weeks. Indirect comparisons suggest that the efficacy of AZA is lower than that of CsA. MTX may be considered as third line treatment option for short-term induction treatment and long-term treatment up to 24 weeks, but the evidence is limited. INF is also efficacious for severe AD, but safety and tolerability need to be monitored closely. MMF may be a treatment option for maintenance treatment of AD after induction treatment with CsA. Evidence for the other treatment options is either of low quality or indicates inferior efficacy.
This review provides evidence-based recommendations on systemic treatment for AD. However, most trials were small and short. To further increase our understanding of the best treatment options for patients with AD who cannot be adequately controlled with topical or UV treatments alone, large long-term head-to-head trials are needed. Furthermore, although prevalence of AD is highest among children, RCTs in children are missing for many relevant interventions, and more research in this age group is recommended.
The Journal of Allergy and Clinical Immunology (JACI) is the official scientific journal of the AAAAI, and is the most-cited journal in the field of allergy and clinical immunology.