Table 3.
Clinical recommendations for treatment of atopic dermatitis (AD) in Africa and the Middle East
| Type of treatment | Recommendation | Merits | Drawbacks |
|---|---|---|---|
| Emollients and moisturizers |
• Emollients should be the mainstay of treatment • Should be applied at least 5 times/day (acute) or 3 times/day (maintenance) |
• Improve skin barrier function and symptoms [16, 70] • Reduce need for prescription anti-inflammatory therapies [16, 71] |
• Insufficient for moderate to severe cases [16, 18] • Greasiness/smell of moisturizer, frequent application, and adverse reactions may lead to poor adherence [72] • Specialized emollients and prescription emollient devices can be costly [16, 20] |
| Topical corticosteroids (TCSs) | • Should be applied 2 times/day for 7 days (acute); then 1 time/day for 7 days or twice weekly (maintenance) |
• Recommended first-line anti-inflammatory therapy [16, 18–20] • Effective with satisfactory safety profile when used as directed [16, 73, 74] • Low cost for prescription therapy with several generic options [74, 75] |
• Potential for long-term local side effects such as skin atrophy and systemic side effects such as HPA axis suppression merits routine monitoring [74] • Limited use in children [74] • Potential for hypopigmentation in patients with skin of color [74] |
| Topical calcineurin inhibitors (TCIs) | • Should be applied 2 times/day for 1 month (acute); then 2 times/week (maintenance) |
• Effective for short- and long-term treatment of mild to severe AD in adults and children [16, 76–79] • Steroid sparing; reduces need for TCS when used for long-term, proactive prevention of flares [80] • Useful for sensitive areas (face, genitals, skin folds) [16, 20] |
• Higher cost prescription therapy [75] • Local tolerability issues (stinging/burning) may require patient counseling to prevent nonadherence [16, 18] • Limited in combination with phototherapy as sun exposure should be avoided during TCI treatment [81, 82] |
| Topical PDE4 inhibitors |
• Crisaborole ointment, 2%, should be applied 2 times/day • Maintenance algorithm is not yet defined |
• Effective treatment for mild to moderate AD in children and adults ≥ 2 years of age [83] with satisfactory short- and long-term safety profile [83, 84] |
• Cost-effectiveness unestablished [85] • Limited real-word effectiveness, head-to-head comparative efficacy, and safety data available [20] • Local tolerability events including application site pain among most common treatment-related adverse events in pivotal [83] and long-term safety trials [84] • Currently approved only in USA [24] |
| Systemic therapies |
• Sedating antihistamines at bedtime; nonsedating antihistamines during the day if necessary • Systemic immunosuppressants (methotrexate, cyclosporine, azathioprine) or biologics as second- or third-line therapies |
• Antihistamines: widely available with low side effect profile (second-generation H1 antagonists) [86] • Systemic immunosuppressants: effective in moderate to severe cases [73, 87, 88] • Biologics: dupilumab effective in moderate to severe cases [89] |
• Antihistamines: efficacy in AD unproven [90], recently associated with ADHD symptoms in children with AD [91] • Systemic immunosuppressants: limited long-term use [17, 73]; pronounced side effect profile necessitates close monitoring [17, 73] • Biologics: very cost intensive [92]; some are investigational and lack long-term safety and efficacy data in AD [17, 18, 21]; dupilumab approved only in USA [25], Europe [25], Canada [26], and Japan [27] |
| Other |
• UV phototherapy if unresponsive to topical therapies • Education regarding appropriate skin care • Avoidance of triggers (e.g., scented soaps) |
• Behavioral modifications and patient education: cost effective with good efficacy [21, 23] • UV phototherapy: effective with good side effect profile [93] |
• UV therapy: high costs (machine and maintenance) [20, 93]; requires patient access to a phototherapy center and frequent visits [20, 93]; limited long-term use and use in hairy/intertriginous areas [93] |
ADHD attention deficit hyperactivity disorder, FDA US Food and Drug Administration, HPA hypothalamic-pituitary-adrenal, PDE4 phosphodiesterase 4