Atopic Dermatitis: Systemic Immunosuppressive Therapy

Abstract

Atopic dermatitis (AD) is a pruritic, relapsing skin disorder that negatively impacts the quality of life of those affected and that of their families. Treatment options for AD encompass a variety of emollients, topical corticosteroids, topical immunomodulators, phototherapy, and systemic agents. Such agents as systemic corticosteroids, cyclosporine, azathioprine, interferon-gamma, methotrexate, and mycophenolate mofetil have been shown to be efficacious in the treatment of moderate-to-severe AD but are not officially approved for this purpose. In this article, we review some of the data supporting efficacy of these medications and discuss some of the adverse events associated with their use.

Contrasting pathogenesis of atopic dermatitis and psoriasis—Part II: Immune cell subsets and therapeutic concepts

“…In patients with recalcitrant AD, systemic immunosuppressive therapies (eg, systemic corticosteroids, CsA, and methotrexate) provide a short-term solution to control inflammation (Table I). 116,117,136,137 Therapy with systemic corticosteroids should be avoided, however, because patients have rebound effects when they discontinue therapy and the drugs have long-term side effects. Systemic corticosteroids should be given only in short courses to stop an acute exacerbation of AD.…”

“…137,142 CsA is a relatively safe treatment for 3 to 24 months for patients who have not responded to other approaches, such as topical therapies, phototherapy, and oral corticosteroids. 136,137 Although CsA is widely prescribed for patients with severe AD, studies of its efficacy lack mechanistic information; Agents that target the innate immune system Oral vitamin D supplementation Probiotics Topical protease inhibitors Agents that target the adaptive immune system Biologic therapies: Reagents that target T cells (alefacept, efalizumab, withdrawn from market) Antibody against IgE (omalizumab) B-cell targeting (rituximab) Anti-TNF reagents (etanercept, infliximab, adalimumab)…”

“…112,138 Antimetabolites, such as methotrexate and mycophenolate mofetil (Cellcept; Roche, Mannheim, Germany), have limited efficacy in patients with AD in whom other treatment strategies have failed. 136,137,149 Several trials have reported that azathioprine is effective in treating moderate-to-severe AD. 117,150 Immunosuppressive drugs, such as mycophenolate mofetil and azathioprine, inhibit T-cell and B-cell proliferation.…”

Furanocoumarins

“…On the other hand, ECP using psoralens is effective for the treatment of severe, therapy-resistant atopic dermatitis and in clearing or reducing erosive lesions in patients with lichen planus [139][140][141][142]. Atopic dermatitis is an immune-mediated, relapsing skin disorder for which treatment options include a variety of emollients, corticosteroids, immunomodulators, and phototherapy [143]. Atopic dermatitis patients who failed to respond to standard first-and/or second-line therapies showed substantial skin responses to ECP treatment within 6-10 cycles, indicating that photopheresis may have beneficial therapeutic effect in patients who are refractory to conventional therapy [144].…”

Therapeutic Management of Atopic Eczema

“…It is for these patients, that we strive to develop new promising systemic treatment options. Up to now, systemic glucocorticosteroids, cyclosporine A, azathioprine and mycophenolate mofetil are the most commonly applied systemic anti inflammatory drugs in AE with their well known limitations and side effects [53].…”