Atopic dermatitis: Recommendations for the use of systemic immunomodulatory agents

  • Systemic immunomodulatory agents are indicated for the subset of adult and pediatric patients in whom optimized topical regimens and/or phototherapy do not adequately control the signs and symptoms of disease. 

  • Systemic immunomodulatory agents are indicated when the patient’s skin disease has significant negative physical, emotional, or social impact.

  • All immunomodulatory agents should be adjusted to the minimal effective dose once response is attained and sustained. Adjunctive therapies should be continued in order to use the lowest dose and duration of systemic agent possible.

  • Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise monitoring protocols for any systemic immunomodulating medication.

  • Treatment decisions should be based on each individual patient's AD status (current and historical), comorbidities, and preferences.

  • Cyclosporine is effective and recommended as a treatment option for patients with AD refractory to conventional topical treatment.
  • Strength of Recommendation: B Level of Evidence: I,II

  • Azathioprine is recommended as a systemic agent for the treatment of refractory atopic dermatitis.
  • Strength of Recommendation: B Level of Evidence: II

  • Methotrexate is recommended as a systemic agent for the treatment of refractory atopic dermatitis. Folate supplementation is recommended during treatment with methotrexate.
  • Strength of Recommendation: B Level of Evidence: II

  • Mycophenolate mofetil may be considered as an alternative, variably effective therapy for refractory atopic dermatitis.
  • Strength of Recommendation: C Level of Evidence: III

  • Interferon gamma is moderately and variably effective and may be considered as an alternative therapy for refractory AD in adults and children who have not responded to, or have contraindications to the use of, other systemic therapies or phototherapy.
  • Strength of Recommendation: B Level of Evidence: II

  • Systemic steroids should be avoided if possible for the treatment of AD. Their use should be exclusively reserved for acute, severe exacerbations and as a short-term bridge therapy to other systemic, steroid-sparing therapy.
  • Strength of Recommendation: B Level of Evidence: II


Navigate section 3 of the AD guideline: Phototherapy and systemic agents 

Citation note

When referencing this guideline in a publication, please use the following citation: Sidbury R, Davis DM, Cohen DE, Cordoro KM, Berger TG, Bergman JN, et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327-49. 

 


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