Expert Perspectives on Collaborative Management of Atopic Dermatitis - Episode 12

Using Systemic Treatment in Atopic Dermatitis

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A review of the safety and efficacy of systemic agents such as methotrexate, azathioprine, and cyclosporine in patients with severe, persistent atopic dermatitis.

Lawrence F. Eichenfield, MD: Let’s move on to the bigger stuff. The next step historically if you can’t control with topicals is either phototherapy, although not necessarily easy to access, or traditional systemic therapies. Methotrexate, azathioprine, and cyclosporine are the traditional agents. They aren’t used that much in either adults or kids. Any comments on those? I’m not sure if Lisa or Peter wants to take the lead on that.

Elizabeth A. Swanson, MD: I’ll chime in. I will commonly say that picking a systemic agent to treat bad atopic dermatitis before we had dupilumab was like picking a port-a-potty out of a row of port-a-potties. You know they’re all going to suck, but you’ve got to pick 1 when you have to go.

I was never excited to put a patient on any of these therapies. It was out of desperation. I didn’t know how else to help them. I was like, “OK, let’s try a cyclosporine,” or, “Let’s try methotrexate.” Their adverse-effect profiles are not great. They’re immunosuppressing agents. There are frequent labs. Thank God we’re at the horizon of better options for people.

Jeffrey M. Bienstock, MD, FAAP: Lisa, I’ve heard you use that port-a-potty analysis before, and it makes me chuckle inside. With what we’re going to talk about next as an agent, we’re probably not going to have to be turning to those drugs anymore. While topical steroids frighten parents and some clinicians, using regimens like that frighten everybody.

Lawrence F. Eichenfield, MD: Some pediatric specialists still use these agents, especially methotrexate and cyclosporine in certain situations. We know from the data that there was never a large number of cases; either kids or adults in the United States. We didn’t have approval for cyclosporine for atopic dermatitis. Methotrexate can be effective in some patients, but we may want to shift to what has been a revolutionary therapy with the introduction of the first prospectively designed biologic for atopic dermatitis with dupilumab. 

Jeffrey M. Bienstock, MD, FAAP: Absolutely.

Transcript Edited for Clarity