When to Choose Systemic Therapy for Pediatric and Adult Atopic Dermatitis
When to think about medicines that work through the whole body for eczema
If you or a child has atopic dermatitis (often called eczema) you may reach a point where creams and ointments just aren’t enough. Mark Lebwohl, MD, a dermatologist at Mount Sinai, talked about when doctors usually consider moving from skin treatments to medicines that work throughout the body (known as systemic therapy), and what factors affect which drug is chosen. (Source: Interview with Mark Lebwohl, MD)
How doctors decide someone is a candidate for systemic therapy
There are a few common ways it becomes clear that topical treatments aren’t cutting it:
- Large area of skin affected: If more than about 10% of the body is involved, it’s often time to consider systemic options. A quick rule of thumb is that 10 palms (your hand, not including fingers) equals roughly 10% of body surface area. (Source: Interview with Mark Lebwohl, MD)
- Frequent flares or heavy treatment use: People who have repeated flares or who spend much of the year using topical medicines may be better served by a systemic medicine.
- Small area but poor response: Even when eczema is limited, if creams and ointments don’t control it well, systemic treatment can be an option.
- Personal preference: Some people strongly prefer to keep trying topicals. In those cases, doctors usually keep working with the best topical strategy possible.
Picking a drug: itch, age, and insurance all matter
Choosing a systemic medicine isn’t only about how bad the rash is. The main symptoms, the person’s age, and insurance coverage often shape the choice.
If itching is the biggest problem, nemolizumab is known to provide fast itch relief and is often chosen for that reason. (Source: Interview with Mark Lebwohl, MD)
Age matters because not every drug is approved for every age. Many medicines aren’t approved for children between ages 2 and 12, so options are more limited in that group. In practice, dupilumab is the medicine most commonly prescribed for younger children when a systemic option is needed. Insurance approval and out-of-pocket cost also play a big role in what doctors can realistically prescribe. (Source: Interview with Mark Lebwohl, MD)
Lebwohl noted that for many patients in these age groups, dupilumab and nemolizumab are the two drugs most often used. Coverage tends to be reasonably obtainable for these drugs, but copays for some treatments can still be high, especially for people on Medicare. (Source: Interview with Mark Lebwohl, MD)
What we know about dupilumab safety
Dupilumab has now been used for more than a decade, and the safety information has held up over that time. The main side effect seen in clinical trials was increased conjunctivitis (eye redness or irritation) in about 10% of patients, roughly one in ten. Other expected issues, like more infections, generally did not show up at higher rates. (Source: Interview with Mark Lebwohl, MD)
About reports of cutaneous lymphoma
There have been some reports of cutaneous lymphoma (a type of lymphoma that affects the skin) in people taking dupilumab. Lebwohl said he usually does not bring this up routinely with patients or parents because the available data suggest many reported cases were cases of diagnostic mix-up: cutaneous lymphoma can look a lot like eczema, and in some situations the true diagnosis was made after treatment started. In other words, the lymphoma may have been present but unrecognized before the drug was given. (Source: Interview with Mark Lebwohl, MD)
Growth and bone concerns in children
Children with uncontrolled, significant eczema who are treated only with topical therapy may show slower growth compared with children whose disease is better controlled. It’s not entirely clear whether this is due to the inflammation itself, steroid absorbed through the skin, or the occasional need for systemic steroids during flares.
Lebwohl noted that children treated with dupilumab tended to grow more than children treated only with topical corticosteroids. Better overall disease control may explain some of this difference. Avoiding frequent or high-dose corticosteroids may also help, because systemic steroids are known to possibly affect bone growth by causing early closure of growth plates. (Source: Interview with Mark Lebwohl, MD)
What this means for you
If eczema is affecting a large part of the body, flaring often, or not improving with creams and ointments, it’s reasonable to talk with your dermatologist about systemic options. Which medicine is right depends on the main symptoms (for example, severe itch), the patient’s age, and what your insurance will cover. These are conversations to have with a dermatologist, who can explain risks, benefits, and practical hurdles like cost and age approvals.
Tracking visible changes
Keeping a simple photo diary or notes about flares can help you and your doctor see whether treatments are working over time and whether the rash is changing in appearance or behavior.
When to see a doctor right away
Contact a healthcare provider if you or your child has rapidly changing lesions, new pain, bleeding, signs of infection (increasing redness, warmth, pus, or fever), or very fast changes in growth or development. These signs need prompt evaluation.
Disclaimer: This article summarizes insights from an interview and is for informational purposes only. It is not medical advice. Treatment decisions should be made with a doctor or dermatologist who knows the patient’s full medical history.
Sources
- Interview with Mark Lebwohl, MD, Dean for Clinical Therapeutics at the Icahn School of Medicine at Mount Sinai and Chairman Emeritus, Department of Dermatology, Mount Sinai. (Source: Interview with Mark Lebwohl, MD)