Management of severe adult atopic dermatitis

In common with many units, we run a specialist atopic eczema clinic that receives both secondary and tertiary referrals. Investigation into possible provoking factors includes RAST testing and patch testing where appropriate. The mainstay of treatment for moderate to severe atopic eczema remains topical steroids and emollients. Our specialist nurses play a key role in education and in particular demonstrating topical treatments − including bandaging. It is surprising that many patients have not previously been shown how to apply the treatments prescribed. Nevertheless, despite optimizing topical treatment protocols, a proportion of patients require hospital admission or second‐line therapy. Our recent double‐blind, randomized, controlled trial of narrow‐band UVII vs. UVA (as used in PUVA) vs. placebo has confirmed that narrow‐band WB phototherapy is an effective adjunctive treatment in moderate to severe atopic eczema. This trial also highlighted the value of recording disease activity (e.g. SASSAD) in individual patients following a change of therapy. UVA1 may be useful for acute severe atopic eczema but this UV source is only available in limited centres within the UK. Selected resistant patients or patients with acute flares are considered for short‐term cyclosporin therapy. Azathioprine is widely used by consultant dermatologists in the UK as a second‐line agent − despite the lack of evidence of efficacy. We are currently conducting a randomized placebo‐controlled trial to address this issue. The importance of checking thiopurine methyl transferase (TPMT) prior to initiating azathioprine therapy has been emphasized. Our pilot data, with a dosage regime based on the TPMT result, suggest that patients may achieve a longer‐term remission after a relatively short course. Mycophenolate mofetil has been reported to be effective in an open trial and methotrexate is also used but there is a lack of published evidence. The advent of topical tacrolimus and ascomycins, which have been shown to be effective in controlled trials, appear to be a promising development in the management of patients with moderate to severe atopic eczema and may lead to reduction in the use of systemic agents.