Systemic Treatment for Atopic Dermatitis
For those who I lost with the lingo in the title, systemic means a medication that is taken by a shot or by pill versus a topical medication that is applied directly to the skin. For many years, the main systemic medication for atopic dermatitis was oral steroids or other medications that suppress the immune system. Over the past few years, a number of new systemic medications have been FDA approved to treat moderate to severe atopic dermatitis. This article is to help all of us, as I catch up on these new medications as well. I do not have many patients with atopic dermatitis so severe that they require these medications, but it is still a good idea to keep apprised with what is new!
Steroids
Steroids are the old school anti-inflammatory. Most often steroids are prescribed as prednisone by mouth and triamcinolone by an injection. I never, ever prescribe a 6-day Medrol Dose Pack. Why? Skin problems never really get better in 6 days. If a patient takes a Medrol Dose Pack, the rash usually flares even worse when the Dose Pack is over. Then, they are back at the square one trying to fix the problem. I usually prescribe a 15-day taper at least of prednisone when it is absolutely necessary. In my office, that is less than once a year for atopic dermatitis. Since oral steroids have been around awhile, we are quite aware of their side effects. Oral steroids increase blood pressure, increase blood sugar, suppress the immune system, cause weight gain and mood changes, and increase the risk of a fracture even with short term use. With longer term use they have even more risks. The American Academy of Dermatology (AAD) guidelines suggest only using topical steroids for short term or in transition to a non-steroid, called steroid-sparing agents. For a more detailed description of side effects with systemic steroids, read here. LINK https://dermnetnz.org/topics/systemic-steroids.
Immunosuppressive agents
A number of older systemic drugs are designed to more globally suppress the immune system. methotrexate, cyclosporine, mycophenolate mofetil and azathioprine. All of these drugs have their own ups and downs. They all suppress the immune system and most require ongoing blood test monitoring to watch for damage to major organs such as the liver or kidneys.
Newer Biologic Medications
A number of newer biologic medications have been recently FDA approved for atopic dermatitis. Biologic medications generally work to target a specific target in the inflammatory cascade of diseases like atopic dermatitis. For an ongoing update of the newest drugs approved see the National Eczema Association website. LINK https://nationaleczema.org/new-treatments.
In atopic dermatitis many of these medications work on IL-4, IL-13 and JAK, which are specific components in the inflammatory cascade of atopic dermatitis. I will highlight a few of the recent ones below. My experience with many of these drugs is limited because they are so new.
(Dupixent). FDA approved in 2017, Dupixent binds to IL4 alpha receptor to prevent IL-13 signaling. It is a subcutaneous injection every other week.
Tralokinumab (Adbry). FDA approved in 2021, Adbry is an IgG4 monoclonal antibody that neutralizes IL-13. It is a subcutaneous injection every 2-4 weeks.
The newest class of biologic medications are JAK inhibitors. Unfortunately, JAK inhibitors have several safety warnings including risk of death for those over 50, cardiovascular disease, blood clots, and increased cancer risk.
Upadacitinab (Rinvoq). FDA approved in 2022. Rinvoq is JAK inhibitor. It is taken orally once a day.
Abrocitinib (Cibinqo). FDA approved in 2022. Cibinqo is also a JAK inhibitor. It is taken orally once a day.
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