Original article
When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council

https://doi.org/10.1016/j.jaad.2017.06.042Get rights and content
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Background

Although most patients with atopic dermatitis (AD) are effectively managed with topical medication, a significant minority require systemic therapy. Guidelines for decision making about advancement to systemic therapy are lacking.

Objective

To guide those considering use of systemic therapy in AD and provide a framework for evaluation before making this therapeutic decision with the patient.

Methods

A subgroup of the International Eczema Council determined aspects to consider before prescribing systemic therapy. Topics were assigned to expert reviewers who performed a topic-specific literature review, referred to guidelines when available, and provided interpretation and expert opinion.

Results

We recommend a systematic and holistic approach to assess patients with severe signs and symptoms of AD and impact on quality of life before systemic therapy. Steps taken before commencing systemic therapy include considering alternate or concomitant diagnoses, avoiding trigger factors, optimizing topical therapy, ensuring adequate patient/caregiver education, treating coexistent infection, assessing the impact on quality of life, and considering phototherapy.

Limitations

Our work is a consensus statement, not a systematic review.

Conclusion

The decision to start systemic medication should include assessment of severity and quality of life while considering the individual's general health status, psychologic needs, and personal attitudes toward systemic therapies.

Key words

atopic dermatitis
azathioprine
biologic
consensus statement
cyclosporine
eczema
methotrexate
quality of life
systemic therapy

Abbreviations used

AD
atopic dermatitis
IEC
International Eczema Council
NB-UVB
narrowband ultraviolet B
QoL
quality of life
SCORAD
SCORing Atopic Dermatitis Score
TCI
topical calcineurin inhibitors
TCS
topical corticosteroid

Cited by (0)

Drs Irvine and Paller contributed equally to this article.

Corporate sponsorship was provided to the International Eczema Council by Abbvie, Amgen, Celgene, Chugai, Galderma, GlaxoSmithKline/Stiefel, the Leo Foundation, Leo Pharma, Lilly, MedImmune/Astrazeneca, Pfizer, Sanofi, Genzyme and Regeneron Pharmaceuticals, and Valeant. The sponsors had no influence on the content and viewpoints in this article. The cost of publication was covered by the International Eczema Council.

Disclosure: Dr Simpson is an investigator for GlaxoSmithKline, Novartis, Regeneron, Vanda, and Tioga and a consultant with honorarium for Celgene, Galderma, Dermira, Genentech, GlaxoSmithKline, Pfizer, Regeneron, and Sanofi. Dr Bruin-Weller is an investigator for Roche and an investigator and consultant for Abbvie and Regeneron/Sanofi, with all fees paid to her institution. Dr Flohr is a consultant with honorarium for Roche/Genentech and Sanofi/Regeneron. Dr Barbarot is a consultant with honorarium for Pierre Fabre Laboratory and Sanofi-Genzyme, a speaker/educator with honorarium for Bioderma, and an investigator with Pierre Fabre Laboratory. Dr Deleuran is an investigator for AbbVie and Sanofi Genzyme and a consultant with honorarium for CKCare Foundation, La Roche Posay, Leo Pharma, Meda Pharma, Pierre Fabre, Regeneron, and Sanofi Genzyme. Dr Bieber is an investigator or consultant or lecturer for Sanofi, Regeneron, Novartis, Roche, Astellas, Galderma, Pfizer/Anacor, GlaxoSmithKline, Lilly, and L′Oréal. Dr Cork is a consultant with honorarium and investigator for Regeneron and Sanofi. Dr Drucker is a consultant with honorarium for Astellas Canada, Prime Inc, Sanofi, and Spire Learning and an investigator for Sanofi and Regeneron. Dr Eichenfield is a consultant with honorarium for Anacor/Pfizer, Galderma, Genentech, Lilly, Regeneron/Sanofi, and Valeant and an investigator for Regeneron/Sanofi. Dr Foelster-Holst is an investigator (with fees paid to her institution) for Astellas, Novartis Pharma, Phamanet, Pierre Fabre, and Regeneron and a consultant with honoraria for ALK/Abbott, Ardeypharm, Astellas, Johnson and Johnson, La Roche Posay, and Neubourg Skin care GMBH and Co. Dr Guttman is a consultant with honorarium for AbbVie, Allergan, Amgen, Anacor, Bristol-Myers Squibb, Celgene, Celsus Therapeutics, Dermira, Drais, Eli Lilly, Escalier, Galderma, Genentech, Glenmark, LEO Pharma, Mitsubushi Tanabe, Novartis, Pfizer, Regeneron, Sanofi, Stiefel/GlaxoSmithKline, and Vitae and principal investigator for Bristol-Myers Squibb, Celgene, Dermira, Janssen Biotech, LEO Pharma, Merck, Novartis, and Regeneron. Dr Nosbaum is a consultant with honorarium for Sanofi. Dr Reynolds is an investigator for BBSRC Case with AstraZeneca, Stiefel/GlaxoSmithKline, Bristol Myers Squib, Genentech, Innovate UK with Stiefel/GlaxoSmithKline, and Wellcome Trust/GlaxoSmithKline and a consultant with honorarium for Genentech. Dr Schmitt is an investigator for ALK, Merck Sharp and Dohme, Novartis, Pfizer, and Sanofi and a consultant with honorarium for Novartis and Roche. Dr Spuls is a consultant with honorarium for AbbVie, Anacor, Leo Pharma, and Novartis and an investigator for Leopharma and Schering Plough; she reports also having been involved in performing clinical trials with many pharmaceutical industries that manufacture drugs used for the treatment of psoriasis and atopic dermatitis. Dr Thyssen is a consultant with honorarium for Leo Pharma, Roche, and Sanofi-Genzyme. Dr Wollenberg is a consultant with honorium for Almiral, Anacor, Astellas, Bioderma, Celgene, Chugai (travel grant), Galderma, Hans Karrer, Leo Pharma, L'Oreal, MEDA, MedImmune, Merck Sharp and Dohme, Novartis, Pierre Fabre, Pfizer, Regeneron, and Sanofi-Adventis and he received research funding from Beiersdorf and Leo Pharma. Dr Irvine is a consultant with honorarium for AbbVie, Anacor, Chugai Pharma, Genentech, and Sanofi Regeneron. Dr Paller is a consultant with honorarium Anacor, Eli Lilly, Galderma, GlaxoSmithKline/Stiefel, Pierre Fabre, Puricore, Regeneron/Sanofi, Roivant, and Valeant and an investigator for Astellas and Pfizer. Drs Ardern-Jones, Vestergaard, Brown, Silverberg, Seyger, Stalder, Su, Takaoka, Traidl-Hoffmann, and Van der Schaft have no conflicts of interest to declare.

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