Phototherapy and Systemic Therapies for Treating Atopic Dermatitis: New Guidelines and Treatment Options

Phototherapy and Systemic Therapies for Treating Atopic Dermatitis: New Guidelines and Treatment Options

A recently updated set of guidelines from the American Academy of Dermatology (AAD) provides evidence-based recommendations for the treatment of adults with atopic dermatitis (AD) using phototherapy and systemic therapies. While most patients can manage their AD with emollients and topical therapies, patients with more severe or widespread AD or those whose AD is unresponsive to topical treatment may benefit from additional therapeutic options.

Phototherapy, a treatment modality that utilizes different wavelengths of light to treat various skin conditions, has shown effectiveness in managing AD. Although there is a lack of high-quality randomized controlled trials (RCTs) evaluating the efficacy and safety of phototherapy specifically for AD, a systematic review commissioned to support the guidelines found narrow-band UV B (313 nm), UVA1 (340-400 nm), and broadband UVB (290-320 nm) to be the most studied therapies. The recommendation for using phototherapy, particularly narrow-band UVB, was made with conditional certainty due to small sample sizes and potential bias.

Biologics, such as monoclonal antibodies, have emerged as a promising option for treating AD. The guidelines highlight the efficacy and safety of dupilumab and tralokinumab, both of which target specific inflammatory pathways involved in AD. Dupilumab has demonstrated significant improvement in AD signs, symptoms, and quality of life, while tralokinumab has shown similar benefits with no major safety concerns. The workgroup unanimously favored dupilumab as a first-line systemic agent for AD treatment.

Janus kinase (JAK) inhibitors, which interfere with intracellular signaling pathways and modulate immune responses, have also shown promise. Upadacitinib and abrocitinib, selective JAK inhibitors targeting JAK-1, have demonstrated high efficacy in reducing AD signs and symptoms. Higher doses have shown the greatest efficacy, but caution must be exercised due to FDA warnings regarding potential risks, such as increased cancer risk and serious cardiovascular events.

Older systemic therapies, including cyclosporine, methotrexate, azathioprine, and mycophenolate, were conditionally recommended based on low certainty evidence. Cyclosporine was found to be more effective than methotrexate, while azathioprine and methotrexate showed similar efficacy. However, these medications come with a higher risk of serious infections and other potential adverse effects.

The guidelines discourage the use of systemic corticosteroids due to their potential adverse effects and lack of strong supporting evidence.

These updated guidelines provide healthcare professionals and patients with valuable insights into the optimal management of AD. By considering patient-specific factors and potential risks, practitioners can tailor treatment regimens to improve disease control and enhance patients’ quality of life.

Frequently Asked Questions (FAQ)

Q: What are the recommended treatment options for atopic dermatitis (AD) in adults?

A: The updated guidelines recommend considering phototherapy, systemic therapies such as monoclonal antibodies (biologics) and Janus kinase (JAK) inhibitors, or oral antibiotics for adults with more severe or refractory AD.

Q: What is phototherapy?

A: Phototherapy is a treatment modality that uses different wavelengths of light to manage various skin conditions, including AD. It is most commonly delivered as narrow-band UVB, UVA1, or broadband UVB.

Q: What are the recommended biologics for AD treatment?

A: The guidelines highlight dupilumab and tralokinumab as effective biologics for AD. Dupilumab targets the IL-4 receptor, while tralokinumab targets IL-13.

Q: What are JAK inhibitors?

A: JAK inhibitors block the JAK-STAT intracellular signal transduction pathway and are approved for various conditions, including AD. Upadacitinib and abrocitinib are selective JAK-1 inhibitors recommended for moderate to severe AD.

Q: Are there any risks associated with these treatments?

A: Phototherapy may have potential adverse effects such as intolerance to heat, increased risk of skin cancer, and sunburn-like reactions. Biologics and JAK inhibitors carry warnings of potential risks of serious infections, cardiovascular events, and other adverse effects, which need to be considered and monitored.

Q: What about older systemic therapies?

A: Cyclosporine, methotrexate, azathioprine, and mycophenolate are conditionally recommended options but come with higher risks of serious infections and organ toxicities. They are not considered first-line treatments due to lower certainty evidence and lack of FDA approval for AD.

(Source: American Academy of Dermatology)

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