SOURCE: Simpson EL, Bruin-Weller M, Flohr C, et al. J Am Acad Dermatol 2017;77:623-633.

Most patients with atopic dermatitis can control their disease with topical agents, including corticosteroids, calcineurin inhibitors (e.g., pimecrolimus, tacrolimus), local hygienic measures (e.g., moisturizers), and, most recently, a topical phosphodiesterase-4 inhibitor (crisaborole). A recent panel of eczema experts convened to provide advice about when clinicians should consider systemic treatment.

Their first recommendation was to optimize topical treatments. Patients refractory to topicals should be assessed for the presence of contact allergy (e.g., patch testing), as well as for the presence of viral, bacterial, or yeast cutaneous disease. Prior to the institution of systemic therapy, a trial of phototherapy should be considered.

If none of these interventions are sufficient, there are five different systemic therapies to consider: azathioprine, cyclosporine, dupilumab, methotrexate, and mycophenolate. At this stage of disease, most patients will be best served by referral to a dermatologic specialist.