Which are most effective topical treatments of Atopic dermatitis?

The researchers reported tacrolimus, pimecrolimus, and moderate-potency topical corticosteroids (TCS) to be among the most effective in improving and maintaining multiple atopic dermatitis (AD) outcomes. They revealed topical antibiotics to be among the least effective.

High-certainty evidence revealed that pimecrolimus improved six out of seven patient-important outcomes -- including itch, AD severity, sleep disturbance, eczema-related quality of life, any adverse events, AD flare, discontinuation of treatment due to adverse events. Both high and low-dose tacrolimus improved five of seven.

With moderate- to high-certainty evidence, TCS in Groups 4 and 5, indicating moderate potency, improved four and six of these outcomes, respectively. Whether used alone or in combination with other treatments, topical antibiotics were shown to be one of the least effective options.

Atopic dermatitis is a common skin condition with multiple topical treatment options, but comparative effects are uncertain. Derek K. Chu, McMaster University, Hamilton, ON, Canada, and colleagues systematically synthesized the benefits and harms of AD prescription topical treatments.

For the 2023 AAAAI/ACAAI JTFPP AD guidelines, the researchers searched online databases for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data and evaluated the risk of bias. Random-effects network meta-analyses addressed AD severity sleep, itch, AD quality of life, harms, and flares. Topical corticosteroids were classified using seven classes—group 1 being the most potent.

The authors reported the following findings:

· 219 included trials comprising 43,123 patients evaluated 68 interventions.

· With high certainty, pimecrolimus improved six of seven outcomes—among the best for two; high-dose tacrolimus (0.1%) improved five—among the best for two; low-dose tacrolimus (0.03%) improved five—among the best for one.

· With moderate-to-high certainty, group 5 TCS improved six—among the best for three; group 4 TCS and delgocitinib improved four—among the best for two; ruxolitinib improved four—among the best for one; group 1 TCS improved three—among the best for two. These interventions did not increase harm.

· Crisaborole and difamilast were intermediately effective, but uncertain harm.

· Topical antibiotics alone or in combination may be among the least effective.

· To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus.

The researchers' team noted that most of the studies were determined to be at low risk for bias, with missing outcome data providing the most frequent risk of bias. The included trials spanned over 50 years of data, but some smaller studies may have been missed.

The researchers wrote, "Despite these limitations, the study findings show that AD is driven by multiple different inflammatory pathways similar to other allergic diseases. There is a need for further research to better help patients choose an AD treatment,"

Reference:

Chu DK, Chu AWL, Rayner DG, Guyatt GH, Yepes-Nuñez JJ, GomezEscobar L, Pérez-Herrera LC, Díaz Martinez JP, Brignardello-Petersen R, Sadeghirad B, Wong MM, Ceccacci R, Zhao IX, Basmaji J, MacDonald M, Chu X, Islam N, Gao Y, Izcovich A, Asiniwasis RN, Boguniewicz M, De Benedetto A, Capozza K, Chen L, Ellison K, Frazier WT, Greenhawt M, Huynh J, LeBovidge J, Lio PA, Martin SA, O’Brien M, Ong PY, Silverberg JI, Spergel JM, Smith Begolka W, Wang J, Wheeler KE, Gardner DD, Schneider L, Topical treatments for atopic dermatitis (eczema): systematic review and network meta-analysis of randomized trials, Journal of Allergy and Clinical Immunology (2023), doi: https://doi.org/10.1016/j.jaci.2023.08.030.