Most patients with AD can get sufficient control of their condition through lifestyle changes, regular emollient use, identification and avoidance of triggers and application of topical treatments. But for some individuals, this isn’t enough. These tend to be people with severe AD whose condition covers large areas of their body or for whom topical treatments don’t successfully suppress the condition. Systemic treatments are medications that act on the whole body not just the site of the problem (like topical steroids). 

These groups of medications all work by suppressing the body's immune system - tackling the dysregulated inflammatory response described on the condition page. As previously described the benefit of suppressing the immune system is reducing inflammation with the subsequent benefit of helping restore the skin’s barrier function.

If we categorise these medications there are: 

1. Oral steroids - typically only used for short-term relief to tackle severe flares

2. Ciclosporin, methotrexate, azathioprine and mycophenolate mofetil - long term options for condition suppression

3. Monoclonal antibodies - Dupilumab & Tralokinumab - a new generation of injectable treatment for long-term suppression.

4. JAK-inhibitors - Ruxolitinib, Upadacitinib, Abrocitinib - creams and tablets that tackle new signalling pathways in inflammation

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When are they used?

Taking a daily tablet that effectively suppresses the condition sounds great right? Unfortunately, most of these medications have significantly associated side effects meaning they are used only when deemed absolutely necessary. Decisions on the suitability of these medications are made by specialists on a risk-benefit basis - if someone has severe eczema that’s impacting every aspect of their life then the benefits may outweigh the risks.

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Catagories of systemic therapies:

Oral steroids (corticosteroids) ‍

Are really good for gaining quick control of inflammation and can be used as a circuit breaker for severe flares, they can be used short-term but if taken long-term can lead to the weakening of the body's bones (osteoporosis), weight gain and type 2 diabetes. A short course of oral steroids can result in eczema rebound and can make people worse after stopping them. 

Ciclosporin, methotrexate, azathioprine and mycophenolate mofetil

All work by suppressing the body's immune system. They are all fairly old medications which are used in many other conditions such as rheumatoid arthritis, inflammatory bowel disease and preventing rejection of organ transplants. They can all be used long-term to suppress severe AD. They only work while being taken and will not cure the condition (flares may come back if the medication is stopped). They all have significant potential side effects and require regular blood tests and specialist supervision. 

Dupilumab

‍Is from a new family of medications called biologics. These medications provide a more targeted action than old-style immunosuppressants. Dupilumab acts specifically on allergic inflammation and is also used in asthma and chronic severe hay fever. Dupilumab is delivered via an injection every 2 weeks. Though Dupilumab has far fewer side effects than the typical immunosuppressants (sounds great if you don’t hate injections) it is currently a very expensive treatment costing £600 per injection and therefore it is only available in the NHS to those with severe AD.

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