The Topical Toolbox: A Review of Atopic Dermatitis Treatment Options
Panelist discusses how the current treatment guidelines include four classes of topical therapies, with newer non-steroidal options like JAK inhibitors and PDE4 inhibitors providing effective alternatives to long-term corticosteroid use.
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The American Academy of Dermatology's latest atopic dermatitis guidelines recognize four primary classes of topical treatments, all receiving strong recommendations for clinical use. Topical corticosteroids remain the workhorse therapy, available in various strengths that should be matched to treatment areas, though they're intended for intermittent rather than long-term use due to potential side effects. Topical calcineurin inhibitors (tacrolimus and pimecrolimus) serve as effective steroid-sparing agents approved for patients as young as two years old, though they commonly cause burning and stinging sensations that limit tolerability. Despite FDA black box warnings derived from oral transplant medicine data, extensive long-term safety studies spanning over ten years show no increased cancer risk with topical calcineurin inhibitor use, providing reassurance for clinicians and patients.
Phosphodiesterase-4 (PDE4) inhibitors represent significant advancement in non-steroidal topical therapy options. Crisaborole ointment, approved for patients as young as three months, marked the first innovation in this class but suffers from burning sensations and greasy ointment vehicle limitations. Roflumilast 0.15% cream represents a next-generation PDE4 inhibitor offering superior potency, better vehicle formulation, and improved tolerability without burning or stinging, approved for patients six years and older. These medications provide valuable alternatives for patients requiring long-term topical therapy without corticosteroid exposure concerns, expanding treatment options for pediatric and adult populations.
JAK inhibitors and novel mechanism therapies offer the most potent non-steroidal options currently available for atopic dermatitis treatment. Topical ruxolitinib 1.5% cream, approved for patients 12 and older, functions as a cytokine signaling interrupter and likely represents the most effective non-steroidal topical therapy available. Tapinarof 1% cream introduces a completely novel mechanism as an aryl hydrocarbon receptor agonist that modulates rather than suppresses immune function, approved for patients as young as two years with once-daily application convenience. This expanding arsenal of non-steroidal options enables clinicians to move beyond reactive corticosteroid-only approaches, implementing comprehensive treatment strategies that combine initial corticosteroid clearing with long-term non-steroidal maintenance therapy tailored to individual patient needs and preferences.
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