ATOPIC DERMATITIS (ECZEMA) 

Atopic dermatitis, also known as eczema, is more than just an itchy rash. It is often associated 
with other allergic conditions, especially asthma and seasonal allergies/hay fevers. Patients with 
atopic dermatitis are also more prone to skin infections, especially with the herpes virus and 
bacteria such as staph aureus and strep, including methicillin resistant staph (MRSA). Though it 
usually starts in childhood, the disease can go into remission and recur later in life and there 
are reports of atopic dermatitis starting in late adulthood. If you have been told you have eczema, 
you may have atopic dermatitis, but there are many itchy red rashes that are not atopic dermatitis 
and may not respond to some of the newer treatments that are so effective specifically for atopic 
dermatitis. Treatment options range from creams, immunosuppressants and clinical trials. The choice 
depends on disease severity and impact on quality of life.

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Patients with atopic dermatitis should moisturize daily and avoid skin irritants. Their skin has a 
hard time holding onto water and lipids, so they should avoid long hot showers and baths and use 
soap only under the arms and in the groin where bacteria grow. We can recommend appropriate 
moisturizers and cleansers. Patients with atopic dermatitis are also more prone to contact 
dermatitis, so we do recommend staying away from products with dyes and fragrances.

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Topical treatments
1. Topical corticosteroids
These are the mainstay of treatment and can be very effective for limited disease. Pros: cheap and 
accessible
Cons: not suitable for long term use, can cause irreversible thinning of the skin, often stop 
working with continual use, can be uncomfortable if greasy

2. Topical calcineurin inhibitors (Elidel, Protopic) Pros: do not thin skin, safe for eyelids, face 
and groin
Cons: not as potent as topical corticosteroids, expensive, sting, warning for increasing risk of 
lymphoma under age 2 (but this is inaccurate)

3. Topical phosphodiesterase inhibitors (Eucrisa) Pros: do not thin skin, safe for eyelids, face 
and groin
Cons: not as potent as topical corticosteroids, expensive, sting

4. Topical JAK inhibitors (in clinical trials) Biologic treatment

Dupixent and Adbry:

These are the two of the FDA approved systemic therapies for atopic 
dermatitis, but more than 25 other biologics are in development and may become available in the 
future. Making it an exciting time for clinical trails. Dupixent is approved for ages 12 and up, 
and is very safe. The FDA does not even consider this medication an immunosuppressant. Adbry is the 
newest FDA approved and is indicated at this time for adults and both are dosed every other week.

CLINICAL TRIALS:

New molecules are in development for atopic dermatitis in children and adults. 
Please feel free to ask about clinical trials as this represents an opportunity for you to receive 
new cutting-edge therapy. Clinical trails are at no cost to you for participation, the medications 
are free to you while you participate usually for anywhere from 1- 3 years, and you may receive a 
travel stipend while participating.

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UV LIGHT THERAPY:
UV light therapy can be used for widespread disease or localized disease with the excimer laser. It 
comes in two forms UVB therapy or UVA therapy. Narrow band UVB therapy is safer than broad band UVB 
therapy since it only delivers therapeutic wavelengths of light. However, all UVB light can cause 
skin cancer. By delivering only therapeutic wavelengths, the patient generally requires fewer 
treatments to get results, so the safety comes from the lower cumulative UV exposure. The laser 
delivers UVB therapy. UVA therapy is usually given along with a pill that sensitizes the patient to 
light. This form is rarely used to treat psoriasis at this time because of its high risk of skin 
cancer, including melanoma. In addition, post treatment the patient is required to wear sunglasses 
for 24 hours due to persistent sun sensitivity and risk of cataracts. This form of UVA therapy is 
still helpful for other disease states. Sometimes we are able to get a home UV light unit, which 
greatly increases the convenience of this treatment.
PROS: no immunosuppression, safe, effective, easy to use in patients with other medical
problems, such as a history of cancer, heart disease, or kidney or liver disease, no infection risk 
CONS: skin cancer risk, inconvenient if coming to the office and many insurance companies will 
require a co-pay at each visit, usually given 2-3x/week, slow onset, and hyperpigmentation

Immunosuppression:

Though none of these drugs are FDA approved to treat atopic dermatitis, dermatologists have used 
them for decades when the disease is severe enough to warrant the risk. We feel confident managing 
these medications at Medical Dermatology Specialists, but you need to come for regular appointments 
and keep us informed of any concerns or health changes you experience.

Prednisone/corticosteroids:
Prednisone can be given orally, by injection and intravenously. It is remarkably effective for 
atopic dermatitis, but it has many, many side effects and is really only suitable for acute flares. 
It commonly causes worsening of disease after it wears off, and the body can become dependent on 
it.
PROS: effective and fast, cheap
CONS: side effects of long term use include significant weight gain, raised blood sugar including 
new onset diabetes, high blood pressure, bone loss including osteoporosis and fracture, hip fracture (avascular necrosis of the hip bone), glaucoma, cataracts, gastrointestinal ulcers including bleeding ulcers, increased risk of infection, increased risk of heart disease, bruising, thinning of the skin. Short term side effects include irritability, increased appetite, 
insomnia, and acute increases in blood sugar. Must be used with extreme caution in patients with or 
at risk for diabetes.

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Methotrexate:
Methotrexate is a very old medication, originally developed to treat leukemia. It works by 
decreasing the body’s production of white blood cells. At high doses, methotrexate has deadly side 
effects, but at the modest doses used to treat psoriasis it can be very safe and effective, as long 
as it is used correctly. Methotrexate is used in many autoimmune diseases and rheumatologists 
frequently use it for pediatric autoimmune disease. It can be particularly helpful for disease on 
the hands and feet and can be used along with other systemic medications. It is very frequently 
prescribed for patients with psoriatic arthritis, and is also sometimes given in order to maintain 
the efficacy of biologic medications. Because it has been available for decades, the side effects 
of this drug are well known, and it has a long record of safety in patients with other medical 
problems, including a history of cancer. Pregnancy and blood donation are forbidden while on 
methotrexate as it can cause fetal loss (spontaneous abortion) and birth defects.
PROS: can be very effective, cheap, known track record including in pediatric patients, also treats 
psoriatic arthritis
CONS: weakens the immune system (though less than other immunosuppressants), can have severe drug 
interactions, AND CAN NEVER BE TAKEN WITH SULFA ANTIBIOTICS BECAUSE IT CAN CAUSE A FATAL DRUG 
INTERACTION. Metabolized through the liver and cannot be used in patients with a history of liver of disease, heavy alcohol 
use, patients are not allowed to consume alcohol while taking this medication and must limit 
Tylenol use. Can cause nausea, diarrhea, hair loss and sun sensitivity.

Azathioprine (Imuran):

Azathioprine works by blocking the synthesis of new white blood cells. It is readily absorbed from 
the GI tract and generally stronger and more immunosuppressive than methotrexate. Both drugs will 
take about 3 months to start to work.
PROS: inexpensive, well absorbed, more effective than methotrexate
CONS: can cause acute allergic reaction with nausea and vomiting with 1-2 days of taking, can cause 
liver injury starting 3-6 weeks after taking medication which generally resolves after stopping the 
medication but will prohibit further use of the medication (occurs in 1% of patients), weakens 
vaccine response, increased risk of infection, skin cancer and possible increased risk of lymphoma 
with prolonged use. Can also cause hair loss.

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Mycophenolate mofetil (Cellcept):

Cellcept does not cause liver injury or kidney damage. It can cause nausea and constipation and is 
not as predictably absorbed from the bloodstream as azathioprine, but there is no risk of acute 
vomiting or liver enzyme elevation. It is commonly used for autoimmune disease and has minimal drug 
interactions.
PROS: no drug interactions, no end organ damage
CONS: as listed above, immunosuppressive, decreased vaccine efficacy, increased risk of infection 
and possibly lymphoma with prolonged use.

. Cyclosporine
This medication is a potent immunosuppressant most often used for patients who have received an 
organ transplant. It is remarkably fast and effective across many types of psoriasis, but is 
generally only used for patients with severe and/or difficult to treat disease because it has many 
side effects and requires close monitoring.
PROS: fast, effective even for severe disease
CONS: many side effects including permanent kidney damage, even kidney failure, serious infections, 
increased risk of lymphoma (cancer of the white blood cells) with prolonged use and skin cancer, 
high blood pressure, gout and other problems. Frequent clinic visits with lab draws and blood 
pressure checks required to protect your health.