Table 1.
Treatments for atopic dermatitis in older adults
| Treatment options | Points of note | Problems |
|---|---|---|
| Basic treatments | ||
| Avoidance of exacerbating factors | Avoiding exacerbating factors such as environmental exposure to allergens, irritants, and pathogens in living spaces and lifestyles may improve AD symptoms | For older patients with AD, avoiding these environmental stimuli may become difficult because of their potentially decreased in activities of daily living, cognitive function, and self-care ability |
| Application of moisturizers |
External moisturizers should be used as a basic treatment to improve dry skin of older patients with AD Moisturizers should be used on a wide range of skin surfaces, both lesional and non-lesional skin, and use should be continued after the lesion has healed |
For older patients, long-term wide-ranging external treatment becomes a burden of disease |
| Topical corticosteroids | Topical corticosteroids in combination with a moisturizer should be applied once or twice a day in cases of elderly AD. The frequency of application or potency of topical corticosteroids should be reduced when symptoms improve | Topical medication with the use of multiple external drugs may become difficult because of older patients’ lower self-care ability |
| Topical calcineurin inhibitors: tacrolimus | Topical tacrolimus is useful for skin lesions on sensitive skin areas, including the face and neck, forearm, and dorsum manus, where local adverse effects, e.g., atopic red face, dirty neck, skin atrophy, and steroid purpura, may occur with long-term application of topical corticosteroids | Older patients with AD tend to discontinue topical tacrolimus easily when irritative symptoms develop as an adverse effect of topical treatment. Therefore, explanation of this adverse effect is essential to increase treatment adherence |
| Oral antihistamines/anti-allergic drugs | Oral antihistamines are generally recommended as an adjuvant therapy for topical treatment of anti-inflammatory drugs and moisturizers | Clinicians must be careful of adverse effects of these drugs due to their sedative and anti-cholinergic actions, e.g., sleepiness, unsteadiness, impaired performance, urinary retention, and glaucoma |
| Additional treatment options | ||
| Oral corticosteroids | Oral corticosteroids administered in small doses (5–15 mg/day or 0.1–0.2 mg/kg body weight/day in prednisolone-equivalents) and with careful attention to adverse effects may be useful for moderate-to-severe cases of elderly AD | Appropriate monitoring and prevention of adverse events, e.g., hypertension, peptic ulcer disease, cataract, osteoporosis, diabetes mellitus, infection, adrenal function suppression, and steroid purpura, are required |
| Oral cyclosporine (ciclosporin) |
Oral cyclosporine is effective for the treatment of severe cases of elderly AD at a dose of approximately 3 mg/kg/day Oral cyclosporine for older patients with AD should be administered for no longer than 12 weeks |
Clinicians must pay attention to the increased risk of malignancy such as non-melanoma skin cancer or lymphoma and organ toxicity, especially of the cardiovascular system and kidney, with long-term cyclosporine treatment in older patients with AD |
| Phototherapies: narrow-band ultraviolet B | Narrow-band ultraviolet B at a dosage of approximately 0.35–0.70 J/cm2 per irradiation could be useful for the treatment of elderly AD as an adjunctive therapy | Regular visits to the hospital every week or every other week for continuous irradiation may be a burden of disease for older patients with AD |
| Biologics: dupilumab | Dupilumab therapy (subcutaneous injection of 300 mg every 2 weeks after a loading dose of 600 mg) markedly improves skin lesions and itch in older patients with AD, with rapid response and non-serious adverse effects |
Injection pain, expensive medical care, and regular visits every 2 weeks for therapy may become a burden of disease in dupilumab therapy Self-injection at home might be difficult for older patients who have a potentially decreased self-care ability |
| Other treatments and new drugs |
In moderate-to-severe cases, hospitalization for basic treatments with or without additional therapies is useful for the management of elderly AD As simultaneous treatment for complications, several off-label therapies, e.g., omalizumab (anti-IgE), might be used with an expected but uncertain therapeutic effect |
Several new drugs, e.g., H4R-blocking antihistamines, JAK inhibitors, and anti-IL-31 receptor antibody, might be approved in the near future. A topical PDE4 inhibitor is already approved in North America. However, the efficacy and safety of these new drugs for older patients with AD are still uncertain |
AD atopic dermatitis, H4R histamine H4-receptor, IgE immunoglobulin E, IL interleukin, JAK Janus kinase, PDE4 phosphodiesterase 4