Moderate-to-Severe Atopic Dermatitis When Allergen Immunotherapy Has Not Achieved Adequate Control
This protocol applies to patients with moderate or severe atopic dermatitis who completed or are on allergen immunotherapy alongside standard topical treatment but have not reached the expected level of disease improvement.
Clinical Scenario
The patient presents with moderate or severe atopic dermatitis and is receiving or has received standard topical treatment. Disease control remains insufficient despite the previous therapeutic step.
Previous Step — Insufficient Response
The prior line added allergen immunotherapy (subcutaneous immunotherapy [SCIT] or sublingual immunotherapy [SLIT]) to standard topical treatment. The target for that step was a reduction in atopic dermatitis severity of 50% or more from baseline, with a median expected time to effect of approximately 5 months.
When that threshold is not reached, this next-line protocol is indicated.
Next-Line Approach (Partial Overview)
The next step involves adding a targeted biologic agent to ongoing topical treatment. Which agent applies depends on patient age and clinical circumstances — the complete selection criteria, full list of options, and combination guidance are available in the full protocol.
Treatment Goals
The aims of this protocol are reduction in atopic dermatitis severity, itch, and sleep disturbance, and improvement in AD-related quality of life.
References
DOI: 10.1016/j.anai.2023.11.009
- Recommendation 16: In patients 6 months of age or older with moderate-severe AD refractory, intolerant, or unable to use mid-potency or greater topical treatment, the JTF panel recommends adding dupilumab over continued standard topical treatment without dupilumab (strong recommendation, high-certainty evidence).
- In patients 12 years of age or older with moderate-severe AD refractory, intolerant, or unable to use mid-potency topical treatment, the JTF panel recommends adding tralokinumab over continued topical treatment without tralokinumab (strong recommendation, high-certainty evidence).
- The linked systematic review and NMA of 149 RCTs evluating 75 interventions in 28,686 patients revealed that compared with continued standard topical treatment alone, adding dupilumab led to large improvements in multiple patient-important outcomes (Fig 5 presents an abbreviated summary of findings from systemic NMA) including AD severity, judged either by patients or clinicians, itch, sleep disturbance, AD-related quality of life, without an increase in serious adverse events or adverse events leading to discontinuation.
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