Atopic Dermatitis: Systemic Treatment

Presented by: Eric Lawrence Simpson, MD, FAAD
Professor of Dermatology, School of Medicine, Oregon Health & Science University
Portland, OR, USA

  • Systemic therapy for atopic dermatitis (AD) is often appropriate yet has limitations such as efficacy and the duration for which is can be used.
  • Systemic therapy is often used with concomitant topical corticosteroids
  • Patient education and shared decision making is essential to clinical recommendations, which should reflect the impact of AD on the patient’s quality of life, risks, burdens, and potential outcomes.

Systemic therapies can be used in the treatment of AD as monotherapy or in conjunction with other treatments, for example, in combination with topical corticosteroids. Patient education is essential to create realistic expectations as to the AD prognosis without systemic therapy and with systemic therapy. Systemic therapy is often clinically considered after treatment with topical corticosteroids has failed; therefore, clinicians should revisit the diagnosis to determine if a misdiagnosis caused the topical treatment failure before initiating systemic therapy. The risks and burdens of any course of treatment should be fully explained, along with alternatives, for a shared decision-making approach between clinician and patient.

  • Systemic therapy in the treatment of AD is appropriate in select patients in specific clinically scenarios.
  • Dupilumab is widely used, and its indications and usages are discussed.
  • Current systemic therapy options available in 2019 are safe and effective in treating AD.
  • New and emerging systemic therapies are expected with targets for treating atopic dermatitis including barrier defects, keratinocyte cytokines and dysbiosis.

In determining whether to initiate systemic therapy, clinicians should be guided by factors including the clinical response to topical therapy, impact on patient quality of life, and potential efficacy of systemic treatment [1].

  • If topical treatment has been aggressive, yet has not yielded adequate control of the disease, and moderate to severe skin lesions persists, systemic therapy should be considered. The threshold of adequate control varies with the patient and depends upon their individual priorities regarding appearance, discomfort, and interference with activities.
  • Clinicians should also reconsider the diagnosis (e.g., to rule out infection or allergic contact dermatitis) to ensure that a misdiagnosis does not underlie the topical treatment failure. A biopsy can be considered.
  • Systemics may not be warranted in conditions where there is adult onset, sudden worsening, lack of history of atopy in patient or family, atypical morphology, or atypical distribution.
  • When recommending systemics, clinicians should offer advice and educate the patient appropriately regarding adherence, as well as potential risks and benefits. Clinicians should also consider phototherapy as a non-toxic option.
  • Clinicians should educate patients and caregivers regarding the nature of their AD, long-term expectations, and range of treatment options and results.
  • Clinicians should engage patients in shared decision making so that a reasonable expectation of treatment risks and burdens, likely benefits and long-term outcomes, can be assessed in the context of the patients’ comorbidities and quality of life [2].
  • Patients should be made aware that the AD is a chronic disease, with no cure, stemming from an over active immune system.
  • Patient education should be tailored to a patient’s level of health literacy.
  • While many patients have comorbidities such as food allergies that may play a role in other health conditions, clinicians should clearly advise patients when allergic triggers do not underlie the AD.
  • The extent to which the AD impacts the patient’1s quality of life is a paramount treatment consideration. Without this information, patients may not be able to weigh risks and benefits of systemics in a full context of alternatives.

Several effective systemic treatment options are currently available, including the following:

  • Dupilumab: potential advantages include rapid onset, 80% efficacy, and the potential to be safely used long-term without the need for lab work. Disadvantages include injection administration and potential conjunctivitis in 10-25% of patients.
  • Cyclosporine: potential advantages include rapid onset and 80% efficacy. Disadvantages may include hypertension, peripheral neuropathy, drug interactions, renal dysfunction, labs, 1-year limit, drug interactions, and immunosuppressive properties. Cyclosporine is not recommended for patients with uncontrolled hypertension, history of severe malignancy, or systemic infection.
  • Methotrexate: potential advantages include the potential for long-term use and 50% efficacy. Achieves Eczema Area and Severity Index (EASI) 50 in 87% of those studied at week 20 and is available for use in children [3]. Disadvantages may include slow onset, liver toxicity, and blood count problems [3].
  • Mycophenolate: potential advantages are that there is no renal toxicity or hepatotoxicity and has efficacy comparable to cyclosporine. It is available for use in children and for patient with contraindications to methotrexate [4].
  • Azathioprine: potential advantages are lower costs. It is also available for use in children. Potential disadvantages include a lower rate of efficacy than other systemic agents, and adverse effects involving blood count, liver dysfunction and immunosuppression [5].

Key Messages/Clinical Perspectives

  • Clinicians should use a shared decision-making process with patients.
  • When treating with dupilumab and other systemic agents, communicating safety and efficacy data to patients is a priority.
  • Dupilumab treatment yields a clinically relevant response for most patients.
  • Consult or refer to an ophthalmologist to address conjunctivitis, rather than discontinue dupilumab.
  • Atopic dermatitis treatment is undergoing revolutionary changes and entering a new era that will improve patient outcomes and patient quality of life.


Presenter disclosure(s): The presenter has reported relationships with the following companies: AbbVie; Demira; Eli Lilly and Company; Leo Pharma Inc.; Pfizer Inc.; Pierre Fabre Dermo Cosmetique France; Regeneron.

Written by: Daniel Bennett, MPH

Reviewed by: Martina Lambertini, MD


Welcome to the Highlights from AAD 2019

Prof. Nellie Konnikov, MD, FAAD

We are pleased to present highlights from the 2019 Annual Meeting of the American Academy of Dermatology (AAD). Our meeting was held from March 1 to March 5, 2019 in Washington, DC. The AAD conference … [ Read all ]

Clinical Trials



New and Emerging Therapies for Psoriasis

Presented by: Leon H. Kircik, MD, FAAD



New and Emerging Therapies for Acne and Rosacea

Presented by: Diane S. Berson, MD, FAAD


Meeting the Needs of the Hair Challenged Patient

Presented by: Glynis Ablon, MD, FAAD


New and Emerging Therapies for Atopic Dermatitis

Presented by: David E. Cohen, MD, MPH, FAAD


Update on Control of Excessive Scarring and Keloids

Presented by: Brian Berman, MD, PhD, FAAD


New and Emerging Therapies in Infections of the Skin

Presented by: Theodore Rosen, MD, FAAD



JAK Symposium: Vitiligo

Presented by: John Harris, MD, PhD, FAAD


What's New in Cutaneous Oncology

Presented by: Darrell S. Rigel, MD, MS, FAAD



How Psoriatic Arthritis Affects Choice of Biologics

Presented by: Kristina Callis-Duffin, MD, MS, FAAD


Atopic Dermatitis: Systemic Treatment

Presented by: Eric Lawrence Simpson, MD, FAAD