SummaryBackgroundLittle is known about U.K. dermatologists' treatment approaches towards adult patients with recalcitrant moderate‐to‐severe atopic eczema.ObjectivesWe wanted to learn about (i) treatment approaches used for this disease in the U.K.; (ii) factors that influence treatment decisions and (iii) perceived gaps in evidence on treatment safety and efficacy, and priorities for future trials.MethodsWe conducted an online survey of consultant‐level dermatologists in the U.K.ResultsSixty‐one respondents from over 30 centres reported on management of moderate‐to‐severe atopic eczema in adults, outwith the context of an acute flare. Phototherapy or psoralen–ultraviolet A was the most common therapeutic modality chosen first line (46%), and this was usually narrowband ultraviolet B. Systemic therapy was chosen as a first‐line approach by 36% of dermatologists. Azathioprine was the commonest drug reported being used as first line followed by oral corticosteroids, ciclosporin and methotrexate. Methotrexate was the most common second‐line treatment of respondents. The key factors that influenced decision making on the use of phototherapy and systemic agents were the respondent's clinical experience, results of baseline tests (systemic agents) and knowledge of both efficacy and acute and chronic side‐effect profiles. The most important evidence gaps identified were the relative effectiveness of treatments, the alternatives to current approaches and the safety of long‐term maintenance treatment. With regard to future trials, respondents suggested that priority should be given to studies involving methotrexate.ConclusionsWhile survey study designs have limitations, we found that phototherapy, in particular narrowband ultraviolet B, was respondents' preferred first‐line treatment for adults with recalcitrant moderate‐to‐severe atopic eczema, perhaps reflecting access to, and clinical experience of, this approach. Azathioprine is widely used as a longer‐term maintenance treatment.

References1 Frieling U, Bonsmann G, Schwarz T et al. Treatment of severe lichen planus with mycophenolate mofetil. J Am Acad Dermatol 2003; 49:1063-6. 2 Eisman S, Orteu CH. Recalcitrant erosive flexural lichen planus: successful treatment with a combination of thalidomide and 0AE1% tacrolimus ointment. Clin Exp Dermatol 2004; 29:268-70. 3 Erdem MT, Gulec AI, Kiziltunc A et al. Increased serum levels of tumor necrosis factor alpha in lichen planus. Dermatology 2003; 207:367-70. 4 Simon M Jr, Gruschwitz MS. In situ expression and serum levels of tumour necrosis factor alpha receptors in patients with lichen planus. Acta Derm Venereol (Stockh) 1997; 77:191-3. 5 Eisen D. The clinical features, malignant potential, and systemic associations of oral lichen planus: a study of 723 patients. J Am Acad Dermatol 2002; 46:207-14. 6 Lear JT, English JS. Erosive and generalized lichen planus responsive to azathioprine. Clin Exp Dermatol 1996; 21:56-7. 7 Kopp H, Reymann FE. Lichen planus treated with Grenz rays; preliminary report. Acta Derm Venereol (Stockh) 1956; 36:477-81. 8 Cribier B, Frances C, Chosidow O. Treatment of lichen planus. An evidence-based medicine analysis of efficacy.

The diagnosis of AOSD can be made in the absence of the typical Still's rash but in the presence of other atypical cutaneous features.

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