Several atopic dermatitis therapies under investigation, but mixed results so far

There are a number of factors to consider when deciding how to treat patients with atopic dermatitis, including the severity of the illness, duration of action for particular medications and costs involved in the treatments.

Eric Simpson, MD, assistant professor of dermatology at Oregon Health and Science University discussed these considerations and reviewed data on eczema medications at the 67th Annual Meeting of the American Academy of Dermatology held in San Francisco.

Topical steroids, including fluocinolone acetonide topical oil 0.01% and desonide foam, remain the mainstay of treatment for atopic dermatitis. However, for severe cases of atopic dermatitis, Simpson said cyclosporine remains the mainstay of treatment.

In a meta-analysis of 15 studies with 602 pediatric and adult patients, researchers noted a mean decrease in severe symptoms of 55% or greater even several weeks post-treatment with cyclosporine. However, the researchers also noted increases in creatinine levels, hypertension and gastrointestinal symptoms in those patients. Cyclosporines have the most evidence of efficacy, but their potential toxicities allow only for short courses, up to about three or four months, Simpson said. He recommended 5 mg/kg per day for patients who have failed earlier therapy, but he said it is important to monitor blood pressure and renal function in these patients.

For moderate-to-severe disease, Simpson said that phototherapy should be the first-line therapy. Some studies have noted narrow-band UVB to be more effective in some cases than UVA/B treatment. However, phototherapy carries a potential risk of skin cancer and is not always available — hindering its routine use, particularly in pediatric patients.

Systemic therapies, including azathioprine, mycophenolate mofetil and methotrexate, are being studied as treatments for pediatric patients with atopic dermatitis, but the data so far have shown mixed clinical outcomes. Many patients have shown positive initial responses, but long-term follow-up data on these patients are unavailable. Also, adverse effects, notably gastrointestinal complaints have been affiliated with many of these products.

Lawrence F. Eichenfield, MD, an Infectious Diseases in Children Editorial Board member, said during the meeting, “Newer immunosuppressives such as mycophenolate mofetil can be useful in providing relief for patients with more severe cases of atopic dermatitis. In addition, dosing of azathioprine is now based on an individual’s genetics and metabolic activity to process the medication, allowing it to be used with less chance of dangerous side effects."

Another category of atopic dermatitis therapies is calcineurin inhibitors. In some studies, tacrolimus has been shown even more potent than cyclosporine, but the theoretical risk of oncogenesis led to black box warnings about routine use with this product and another calcineurin inhibitor, pimecrolimus (Elidel, Novartis).

Speaking on the biologics, Simpson said atopic dermatitis patients treated with interferon-gamma showed a 50% or greater improvement vs. placebo in one study, but the rate of headaches, myalgias and chills were greater in the treatment group.

Efalizumab (Raptiva, Genentech) has issues of flaring after discontinuation that mirror other atopic dermatitis treatments. One report of thrombocytopenia in a pediatric patient led to discontinued use. In addition, the FDA recently reported on three confirmed cases and one possible case of progressive multifocal leukoencephalopathy in patients aged 47 to 73 years who were using efalizumab for the treatment of moderate-to-severe plaque psoriasis.

Simpson said no other biologic shows promise yet and recommended interferon-gamma should be used for severe recalcitrant disease. He cautioned it is an expensive treatment. He cited one systematic review of probiotics that noted “doubtful clinical significance” of using probiotics for atopic dermatitis treatment. – by Colleen Zacharyczuk

For more information:

Simpson E. #F043. Presented at: the 67th Annual Meeting of the American Academy of Dermatology; March 6-10, 2009; San Francisco.