The treatment of atopic dermatitis with systemic immunosuppressive agents

Abstract

Atopic dermatitis (AD) is a chronic, relapsing skin disease that typically occurs in individuals with a personal or family history of atopy ie, hay fever, asthma, or AD itself. Typically beginning in early childhood, the disease affects approximately 7 to 17% of the pediatric population. Although in many cases there is moderation of the disease with increasing age, it may persist into adulthood in up to 60% of patients. AD can be managed in many patients with topical therapies, sometimes supplemented by systemic antibiotics, but some individuals, typically those with widespread disease or recalcitrant local disease that interferes with the quality of life, require more aggressive treatment. Management should embrace measures to control environmental “flare factors” such as house dust mites or in young children, certain foods. In addition, coincident skin infection, emotional distress, xerosis from dry ambient air or excessive bathing, and high temperatures causing sweating-induced exacerbations should be addressed with allergen avoidance, antibiotic therapy, relaxation techniques, bathing and skin hydration, humidification, and air conditioning, respectively. If control of flare factors combined with aggressive topical therapy or phototherapy fail to control symptoms of AD, a number of systemic immunomodulatory agents may play a role in treatment (Table 1). Because these agents have significant side effects, utmost care should be exercised in their use. It is also crucial to realize, particularly when contemplating the use of these agents in children, that none of them is approved for the treatment of AD in the United States. Informed consent, preferably in writing, for off-label use in the treatment of AD, should be obtained. Patients should be given written documentation of possible adverse effects and the treatment regimen should be tailored to each patient to limit overall exposure to the systemic agent. Although an extensive discussion of immunopathogenesis (see Kang et al, this issue) is beyond the scope of this paper, a basic understanding of the role of various immune cells and mechanisms in the causation of AD helps to clarify the rationale for using these agents.