The adverse effect profile of oral azathioprine in pediatric atopic dermatitis, and recommendations for monitoring

Neutrophils in Atopic Dermatitis

Neutrophils have a critical role in inflammation. Recent studies have identified their distinctive presence in certain types of atopic dermatitis (AD), yet their exact function remains unclear. This review aims to compile studies elucidating the role of neutrophils in AD pathophysiology. Proteins released by neutrophils, including myeloperoxidase, elastase, and lipocalin, contribute to pruritus progression in AD. Neutrophilic oxidative stress and the formation of neutrophil extracellular traps may further worsen AD. Elevated neutrophil elastase and high-mobility group box 1 protein expression in AD patients' skin exacerbates epidermal barrier defects. Neutrophil-mast cell interactions in allergic inflammation steer the immunological response toward Th2 imbalance and activate the Th17 pathway, particularly in response to allergens or infections linked to AD. Notably, drugs alleviating pruritic symptoms in AD inhibit neutrophilic inflammation. In conclusion, these findings underscore that neutrophils may be therapeutic targets for AD symptoms, emphasizing their inclusion in AD treatment strategies.

Comparison of Oral Azathioprine and Oral Mini Pulse Steroid in the Treatment of Vitiligo: An Open-Label Randomized Controlled Trial

Background

Vitiligo is a common acquired depigmentory skin disorder supposed to be of autoimmune aetiology. Different immunosuppressants have been tried with varying success. Azathioprine has been less studied in vitiligo.

Aims and Objectives

To study the efficacy of oral azathioprine and compare with systemic steroid in the treatment of vitiligo.

Materials and Methods

It was an interventional study with multi-armed (three), parallel group, an open-label, randomized controlled trial with allocation ratio of 1:1:1. Patients of vitiligo aged between 18 and 60 years having more than 5% body surface involvement were included in the study. Patients were divided into three groups. Group A-patients received oral azathioprine 50 mg OD daily, group B-patients received combination of oral azathioprine 50 mg OD and PUVASOL and group C-patients received combination of betamethasone oral mini pulse (OMP) and PUVASOL. All the groups were treated for 1 year. Repigmentation was evaluated by vitiligo area severity index (VASI), and stabilization was evaluated by vitiligo disease activity (VIDA).

Results

Group A, group B and group C showed 24.24%, 53.24% and 47.28% improvement in VASI score, respectively, at the end of 1 year. Group B and group C showed statistically significant superior repigmentation as compared to azathioprine monotherapy. Though azathioprine and betamethasone showed equivalent efficacy, azathioprine has a better safety profile. Side effects were minimal in azathioprine groups, whereas 50% patients developed various side effects in group C.

Conclusion

Azathioprine is safe and effective option in the treatment of vitiligo.

Improving Psychological Health Outcomes in Children with Atopic Dermatitis

Introduction

Atopic dermatitis (AD) is a chronic inflammatory skin disease that usually develops in early childhood. AD has a significant impact on quality of life and psychological health outcomes in both adults and children. There are increased reported rates of psychiatric comorbidities including anxiety, depression, ADHD and suicidal ideation compared to the general population. Primary caregivers of children with pediatric eczema and their families may also have derangements in psychological health and quality of life. A number of interventions exist for AD and address wellbeing outcomes as an important aspect of effective treatment.

Methods

A comprehensive literature search was conducted using PubMed/Medline, Embase, the Cochrane Central Register of Controlled Trials in February 2023. Published studies up to April 2023 were included related to interventions for childhood AD that included psychological health or quality of life outcomes. These interventions were stratified according to type and evidence quality.

Results

Search strategy revealed a wide variety of interventions with demonstrated improvements in quality of life or wellbeing of patients with pediatric AD or their families. Both pharmacological and non-pharmacological interventions demonstrated effectiveness in improving disease outcomes.

Conclusion

A variety of both pharmacological and non-pharmacological interventions may be employed to improve psychological health outcomes in children with AD.

Medical Management of Pediatric Inflammatory Bowel Disease (PIBD) in the Asia Pacific Region: A Position Paper by the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology, and Nutrition (APPSPGHAN) PIBD Working Group

Pediatric inflammatory bowel disease (PIBD) is rising rapidly in many industrialised and affluent areas in the Asia Pacific region. Current available guidelines, mainly from Europe and North America, may not be completely applicable to clinicians caring for children with PIBD in this region due to differences in disease characteristics and regional resources constraints. This position paper is an initiative from the Asian Pan-Pacific Society for Pediatric Gastroenterology, Hepatology and Nutrition (APPSPGHAN) with the aim of providing an up-to-date, evidence-based approach to PIBD in the Asia Pacific region, taking into consideration the unique disease characteristics and financial resources available in this region. A group of pediatric gastroenterologists with special interest in PIBD performed an extensive literature search covering epidemiology, disease characteristics and natural history, management and monitoring. Gastrointestinal infections, including tuberculosis, need to be excluded before diagnosing IBD. In some populations in Asia, the Nudix Hydrolase 15 (NUD15) gene is a better predictor of leukopenia induced by azathioprine than thiopurine-S-methyltransferase (TPMT). The main considerations in the use of biologics in the Asia Pacific region are high cost, ease of access, and potential infectious risk, especially tuberculosis. Conclusion: This position paper provides a useful guide to clinicians in the medical management of children with PIBD in the Asia Pacific region.

The Use of Azathioprine in Atopic Dermatitis. A Review

Most patients with atopic dermatitis (AD) have a good response to topical treatment. However, some need systemic therapy in order to satisfactorily control the disease. Azathioprine is an accessible drug for patients in many countries, including underdeveloped countries, and therefore it's used by many dermatologists in moderate and severe AD. It is important to have a deep knowledge and understanding about this drug since it is an alternative therapy as a steroid-sparing agent and an affordable one. However, when it comes to systemic therapy for AD, it's not always clear its indications and it is necessary to have a closer follow-up of the patient. In this paper we describe thoroughly it's indications in AD, the mechanism of action of the drug, as well as the interactions, adverse effects, adequate monitoring, and precautions in special population that must be considered when prescribing azathioprine. This review will help dermatologists prescribe it safely to all patients who require it. This article is protected by copyright. All rights reserved.

Immunosuppressive Drugs

Immunosuppressant is a class of medicines that inhibit or decrease the intensity of the immune response in the body. Most of these medications are used to allow the body less likely to resist a transplanted organ. In solid organ transplantation, immunosuppressive agents are needed for the activation of early-stage immunosuppression, the management of late-stage immunosuppression or for the maintenance of organ rejection. The emergence of novel agents and improvements in immunosuppression regimens after transplantation are significant factors leading to this progress. However, these drugs also increase the risk of infection, cancers and specific adverse side effects specific to each agent in patients particularly in pregnant women and fertility issues. Corona virus disease being hot topic of debate is has given positive outcome to immunosuppressive drugs however need more attention in future. Transplant centers across the world utilize multiple immunosuppression protocols; nevertheless, each patient can require an individually formulated immunosuppression regimen to manage the advantages and possible damage of treatment thus eliminating the likelihood of their primary disease recurrence.

Predictors of azathioprine toxicity in children with autoimmune hepatitis

AIM OF THE STUDY

Azathioprine (AZA) is an important steroid-sparing drug in the management of autoimmune hepatitis (AIH). Avoidance of its adverse events that could be severe and carry a risk of mortality in a few cases is important, preferably with cheap and easy assessments that could be feasible in developing countries with the unavailability of molecular assays. Assessment of thiopurine methyltransferase (TPMT), the key enzyme for the inactivation of AZA, as a predictor of AZA toxicity had been a matter of conflict. This work aimed to study the role of TPMT serum level assessment and other host-, disease-, and treatment-related factors in predicting AZA toxicity.

MATERIAL AND METHODS

Sixty-six children with AIH, divided into two groups, were recruited. Group 1 included twelve children with AZA toxicity and group 2 included fifty-four children without AZA toxicities. Both groups were compared for demographic, clinical, laboratory, histopathological, and treatment-related factors, and serum TPMT level, measured by ELISA.

RESULTS

TPMT serum level was comparable in both groups (p = 0.363). Duration of treatment until enzyme normalization and duration of AZA therapy were significantly associated with AZA toxicity (p = 0.007 and p = 0.01, respectively). At the first follow-up treatment with AZA, total leucocyte count (TLC) and neutrophil counts were significantly lower in group 1 (p = 0.005 and p = 0.002, respectively). Moreover, the percentage reduction of TLC and neutrophil counts were significantly higher in group 1 (p < 0.001, for both).

CONCLUSIONS

Monitoring for AZA adverse events in those with the defined predictors of AZA-related adverse events is more important than TPMT assessment.

Atopic dermatitis epidemiology and unmet need in the United Kingdom

Atopic dermatitis (AD), also known as atopic eczema, is a chronic inflammatory skin condition associated with a significant health-related and socioeconomic burden, and is characterized by intense itch, disruption of the skin barrier, and upregulation of type 2-mediated immune responses. The United Kingdom (UK) has a high prevalence of AD, affecting 11-20% of children and 5-10% of adults. Approximately 2% of all cases of childhood AD in the UK are severe. Despite this, most AD treatments are performed at home, with little contact with healthcare providers or services. Here, we discuss the course of AD, treatment practices, and unmet need in the UK. Although the underlying etiology of the disease is still emerging, AD is currently attributed to skin barrier dysfunction and altered inflammatory responses. Management of AD focuses on avoiding triggers, improving skin hydration, managing exacerbating factors, and reducing inflammation through topical and systemic immunosuppressants. However, there is a significant unmet need to improve the overall management of AD and help patients gain control of their disease through safe and effective treatments. Approaches that target individual inflammatory pathways (e.g. dupilumab, anti-interleukin (IL)-4 receptor α) are emerging and likely to provide further therapeutic opportunities for patient benefit.

Immunomodulation With Azathioprine Therapy in Rasmussen Syndrome: A Multimodal Evaluation

OBJECTIVE

To verify safety and efficacy of the corticosteroid-sparing drug azathioprine (AZA) in Rasmussen syndrome (RS), we retrospectively analyzed a cohort of patients with RS recruited in a single pediatric neuroscience center.

METHODS

We compared outcomes in 30 patients with RS who received AZA with 23 patients who were not treated with this drug. We used a multimodal approach to correlate therapy with clinical features (seizures, epilepsia partialis continua [EPC], hemiparesis) and neuroimaging markers of progressive brain atrophy.

RESULTS

AZA was well tolerated; only 1 patient discontinued treatment due to pancytopenia. In 27 of 30 patients receiving AZA, all of whom were corticosteroid responders, corticosteroid therapy could be weaned or reduced without worsening of seizures in 89%. Patients receiving AZA had a lower prevalence of EPC (42% vs 67% in controls) and hemiparesis (64% vs 92%, respectively). Cox regression showed for the AZA group compared to controls a delayed time to (1) EPC (≈2 years, exp[B] = 0.295, 95% confidence interval [CI] 0.108-0.807; p = 0.017), (2) hemiparesis (≈1 year, exp[B] = 0.315, 95% CI 0.137-0.724; p = 0.007), and (3) surgery (≈2 years, exp[B] = 2.068, 95% CI 1.012-4.227; p = 0.046). However, there were no group differences in cognitive decline over time (IQ change per year) or in hemispheric gray matter atrophy on serial MRI scans.

CONCLUSION

AZA treatment appears to slow clinical progression of RS in steroid responders; this will give the greatest advantage in patients in the early stages of the disease in whom surgical decision-making may require further time.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that for pediatric patients with RS AZA is well tolerated and slows hemiparesis and appearance of EPC.

Safety of systemic therapy for noninfectious uveitis

Introduction: The treatment strategies for noninfectious uveitis (NIU) aim to achieve disease remission, prevention of recurrences, and preserving vision, while minimizing the side effects associated with the therapies used.Areas covered: The index review aims to provide a detailed overview of the adverse events and safety parameters associated with the systemic therapies for the management of the NIU.Expert opinion: Despite being the cornerstone of management of acute cases of NIU, long-term corticosteroid use is associated with multi-system side effects, requiring the use of steroid-sparing agents. Adalimumab was recently approved by the FDA for the management of NIU based on the results of VISUAL studies. Similarly, newer drugs targeting various aspects of the inflammatory cascade are being developed. However, until we completely understand the molecular pathways of the inflammatory diseases, the therapeutic profile of these newer agents needs to be broad enough to suppress inflammatory cascade and narrow enough to spare normal cellular processes. Another strategy that has shown some potential in decreasing the systemic side effects is to provide local drug delivery. Therefore, the future of management of NIU is very bright with many novel therapeutic agents and strategies of drug delivery on the horizon.

Alopecia Areata Treated with Oral Azathioprine: A Case Series

Alopecia areata is commonly encountered non scarring alopecia with clinical presentations ranging from localised bald patches to extensive involvement. Clinical course is variable ranging from self limiting disease to chronic relapsing and recalcitrant disease. Topical and oral corticosteroids; nonetheless being front line agents for the treatment of alopecia areata;are not advocated for long term administration due to potentially undesirable systemic side effects. Hence the need of steroid sparing immunosuppresive agents like Azathioprine is warranted which have desired therapeutic action without much systemic adverse effects. We report a case series of 4 patients of alopecia areata treated with systemic azathioprine monotherapy.

Approach to the Assessment and Management of Pediatric Patients With Atopic Dermatitis: A Consensus Document. Section III: Treatment Options for Pediatric Atopic Dermatitis

Because atopic dermatitis (AD) is a chronic, relapsing disease, treatment requires the use of both active therapy to control flares and preventative maintenance therapy to promote integrity of the skin barrier. In this third of four sections, important clinical considerations for the treatment of pediatric AD are reviewed. Emerging therapies in development for pediatric AD are introduced.

New and Emerging Therapies for Pediatric Atopic Dermatitis

Atopic dermatitis (AD) is a chronic, inflammatory skin disease characterized by pruritus, inflammatory erythematous skin lesions, and skin-barrier defect. Current mainstay treatments of emollients, steroids, calcineurin inhibitors, and immunosuppressants have limited efficacy and potentially serious side effects. Recent advances and understanding of the pathogenesis of AD have resulted in new therapies that target specific pathways with increased efficacy and the potential for less systemic side effects. New FDA-approved therapies for AD are crisaborole and dupilumab. The JAK-STAT inhibitors (baricitinib, upadacitinib, PF-04965842, ASN002, tofacitinib, ruxolitinib, and delgocitinib) have the most promising results of the emerging therapies. Other drugs with potential include the aryl hydrocarbon receptor modulating agent tapinarof, the IL-4/IL-13 antagonists lebrikizumab and tralokinumab, and the IL-31Rα antagonist nemolizumab. In this review, new and emerging AD therapies will be discussed along with their mechanisms of action and their potential based on clinical study data.

An update on the topical and oral therapy options for treating pediatric atopic dermatitis

INTRODUCTION

Atopic dermatitis (AD) is one of the most common childhood skin disorders. Multiple mechanisms contribute to the pathology of AD and treatment approaches are directed at these processes.

AREAS COVERED

The purpose of this review is to discuss the chemical treatment options for pediatric atopic dermatitis, including immunomodulators and small molecule inhibitors. A systematic literature search was conducted, and publications were reviewed for applicable treatment guidelines.

EXPERT OPINION

Topical therapy is first-line for pediatric atopic dermatitis. Providers should work closely with patients and caregivers to promote the success of topical treatments. In disease refractory to topical treatments, systemic agents may be considered. Clinical trials are ongoing for the use of biologics in the treatment of pediatric AD. When choosing the most appropriate treatment, physicians should consider the drug efficacy, potential adverse effects, patient adherence, and quality of life for both patients and caregivers. Additional studies are required to determine the safest and most effective doses for systemic therapy in childhood AD.

A Retrospective Study of Systemic Treatment of Severe Atopic Dermatitis With Azathioprine: Effectiveness and Tolerance in 11 Pediatric Patients

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that typically affects children. Severe forms may have a profound effect on patients' quality of life. Some forms are resistant to conventional treatment and require the use of systemic immunosuppressants such as azathioprine (AZA) to adequately manage the disease.

OBJECTIVE

To evaluate the effectiveness and tolerance of AZA in children with severe AD.

PATIENTS AND METHODS

We performed a retrospective study of children with severe AD treated with AZA between January 2007 and May 2017.

RESULTS

We reviewed the cases of 11 patients (6 boys and 5 girls) with a mean age of 13 years (range, 8-18 years). The mean (SD) age at start of treatment was 10.9 (2.2) years (95% CI 8.6-13.1). The mean initial dosage of AZA was 1.8 (0.2) mg/kg/d. We evaluated treatment response after 4 weeks, 12 to 16 weeks, and 6 months. Mean treatment duration was 10.8 (5.7) months. Treatment had to be suspended in 2 patients because of adverse effects. Seven of the 9 remaining patients presented complete or almost complete clearance of the AD after 6 months of treatment.

CONCLUSION

In our experience, AZA is well tolerated and may be considered as a treatment option in children with severe AD resistant to conventional treatment.

Atopic dermatitis

Atopic dermatitis (AD) is the most common chronic inflammatory skin disease, with a lifetime prevalence of up to 20% and substantial effects on quality of life. AD is characterized by intense itch, recurrent eczematous lesions and a fluctuating course. AD has a strong heritability component and is closely related to and commonly co-occurs with other atopic diseases (such as asthma and allergic rhinitis). Several pathophysiological mechanisms contribute to AD aetiology and clinical manifestations. Impairment of epidermal barrier function, for example, owing to deficiency in the structural protein filaggrin, can promote inflammation and T cell infiltration. The immune response in AD is skewed towards T helper 2 cell-mediated pathways and can in turn favour epidermal barrier disruption. Other contributing factors to AD onset include dysbiosis of the skin microbiota (in particular overgrowth of Staphylococcus aureus), systemic immune responses (including immunoglobulin E (IgE)-mediated sensitization) and neuroinflammation, which is involved in itch. Current treatments for AD include topical moisturizers and anti-inflammatory agents (such as corticosteroids, calcineurin inhibitors and cAMP-specific 3',5'-cyclic phosphodiesterase 4 (PDE4) inhibitors), phototherapy and systemic immunosuppressants. Translational research has fostered the development of targeted small molecules and biologic therapies, especially for moderate-to-severe disease.

Practical Management of Immunosuppressants in Dermatology

The treatment of inflammatory and autoimmune diseases is challenging because of their frequency and complexity. Treatment of these diseases is based on the suppression of the patient's immune system using corticosteroids, corticosteroid-sparing immunosuppressive agents, and biologic drugs, making an understanding of the management of immunosuppressive therapy essential. Before an immunosuppressive agent is prescribed, a study must be carried out to identify contraindications, detect latent infections, and determine the most appropriate dose. During treatment, regular monitoring is required to detect adverse effects. The clinician must be familiar with the time lag between start of treatment and onset of the immunosuppressive effect as well as the maximum recommended duration of treatment and cumulative dose for each drug. As dermatologists we are accustomed to using these immunosuppressive agents, but we should have a good knowledge of the guidelines for their use and the monitoring required in each case if we are to reduce variability and avoid potentially serious adverse effects.

Non-topical management of recalcitrant paediatric atopic dermatitis

Atopic dermatitis (AD) is a common chronic, pruritic skin disease in children. As the incidence of AD increases, especially in high-income countries, paediatricians may see an increasing number of recalcitrant AD cases in their practice. Although these cases are principally managed by paediatric dermatologists, it is important for paediatricians to be aware of the use and side effects of non-topical treatment like phototherapy and systemic agents as well as the evidence for alternative treatment, which caregivers may ask about. This review presents paediatric evidence for the practical use of phototherapy and certain oral immunosuppressants for paediatric AD including doses, duration of use and monitoring of adverse effects. The use of alternative therapy including traditional medicine, probiotics and the role of nutrition are also discussed. Narrow band ultraviolet B phototherapy is effective in recalcitrant paediatric AD. When phototherapy is ineffective or contraindicated, systemic drugs may be administered cautiously with close surveillance of side effects. The use of azathioprine, ciclosporin, methotrexate and mycophenolate mofetil is generally safe in the short term under close monitoring and can be effective alongside compliance to topical treatment. Alternative complementary treatment is not known to be effective. Holistic management including therapeutic patient education is important. Good quality paediatric studies for non-topical AD treatment are needed for definitive guidelines.

New Perspectives in the Treatment of Atopic Dermatitis in the Pediatric Population

Treatment of children diagnosed with atopic dermatitis (AD) is an art. Age-dependent barrier function, skin physiology, body surface:weight ratio, the compliance of patient and caregivers, and legal considerations related to the license status of topical and systemic drugs must be considered. Mild to moderate AD can usually be treated sufficiently with a personalized regimen of emollients and topical anti-inflammatory therapy consisting of topical corticosteroids (TCSs) or topical calcineurin inhibitors. Emollients containing bacterial lysates, tailored wet wrap regimen, and proactive therapy with tacrolimus ointment or some TCSs are new developments in the field. Severe AD may need systemic therapy, but all currently available systemic agents for severe AD are either not licensed for children or not advisable on the long term, or both. Therapeutic patient education based on structured, interactive sessions with patients or caregivers and a multidisciplinary team is highly effective. This publication summarizes the current therapeutic options used in the pediatric AD population.

Monitoring recommendations for oral azathioprine, methotrexate and cyclosporin in a paediatric dermatology clinic and literature review

BACKGROUND/OBJECTIVES

Systemic oral immunomodulators azathioprine, methotrexate and cyclosporin are widely used in paediatric dermatology. Routine blood tests are performed to minimise drug-related adverse events. However, the frequency of monitoring tests may lead to significant fearful experiences for patients. We reviewed haematological abnormalities and clinical side-effects in a paediatric clinic population commencing immunomodulators for dermatological conditions, where haematological profiles are monitored less frequently than in current recommendations.

METHODS

A retrospective chart review of children started on azathioprine, methotrexate or cyclosporin for a dermatological condition between 2001-2015 from a primarily paediatric, private dermatology practice was performed. Blood tests were done at baseline, 1 month, 2 months and then 3-monthly for children on azathioprine. Children on methotrexate and cyclosporin had tests done at baseline, after 1 month and then 3-monthly.

RESULTS

In total, 242 children were included in this study. Azathioprine, methotrexate and cyclosporin cohorts had 95, 97 and 50 patients treated for a mean duration of 656, 758 and 313 days, respectively. Isolated abnormal blood tests indicated the cessation of azathioprine in 3/95 (3%), methotrexate in 5/97 (5%) and cyclosporin in 2/50 (4%) of patients. Abnormal blood test results were not associated with any reported clinical side-effects in the azathioprine (P = 0.726), methotrexate (P = 0.06) or cyclosporin groups (P = 0.250).

CONCLUSION

In our experience, less frequent monitoring did not result in any significant adverse events over a 15-year period. We suggest that haematological monitoring during immunosuppressants use can be safely reduced from current recommendations.

Atopic dermatitis

Atopic dermatitis (also known as atopic eczema) is a chronic inflammatory skin disease that is characterised by intense itching and recurrent eczematous lesions. Although it most often starts in infancy and affects two of ten children, it is also highly prevalent in adults. It is the leading non-fatal health burden attributable to skin diseases, inflicts a substantial psychosocial burden on patients and their relatives, and increases the risk of food allergy, asthma, allergic rhinitis, other immune-mediated inflammatory diseases, and mental health disorders. Originally regarded as a childhood disorder mediated by an imbalance towards a T-helper-2 response and exaggerated IgE responses to allergens, it is now recognised as a lifelong disposition with variable clinical manifestations and expressivity, in which defects of the epidermal barrier are central. Present prevention and treatment focus on restoration of epidermal barrier function, which is best achieved through the use of emollients. Topical corticosteroids are still the first-line therapy for acute flares, but they are also used proactively along with topical calcineurin inhibitors to maintain remission. Non-specific immunosuppressive drugs are used in severe refractory cases, but targeted disease-modifying drugs are being developed. We need to improve understanding of the heterogeneity of the disease and its subtypes, the role of atopy and autoimmunity, the mechanisms behind disease-associated itch, and the comparative effectiveness and safety of therapies.

Consensus Conference on Clinical Management of pediatric Atopic Dermatitis

The Italian Consensus Conference on clinical management of atopic dermatitis in children reflects the best and most recent scientific evidence, with the aim to provide specialists with a useful tool for managing this common, but complex clinical condition. Thanks to the contribution of experts in the field and members of the Italian Society of Pediatric Allergology and Immunology (SIAIP) and the Italian Society of Pediatric Dermatology (SIDerP), this Consensus statement integrates the basic principles of the most recent guidelines for the management of atopic dermatitis to facilitate a practical approach to the disease. The therapeutical approach should be adapted to the clinical severity and requires a tailored strategy to ensure good compliance by children and their parents. In this Consensus, levels and models of intervention are also enriched by the Italian experience to facilitate a practical approach to the disease.

Systemic Agents for Severe Atopic Dermatitis in Children

Atopic dermatitis (AD), or eczema, is a chronic inflammatory skin condition characterized by relapsing pruritic, scaly, erythematous papules and plaques frequently associated with superinfection. The lifelong prevalence of AD is over 20 % in affluent countries. When a child with severe AD is not responding to optimized topical therapy including phototherapy, and relevant triggers cannot be identified or avoided, systemic therapy should be considered. If studies show early aggressive intervention can prevent one from advancing along the atopic march, and relevant triggers such as food allergies cannot be either identified or avoided, systemic therapy may also play a prophylactic role. Though the majority of evidence exists in adult populations, four systemic non-specific immunosuppressive or immunomodulatory drugs have demonstrated efficacy in AD and are used in most patients requiring this level of intervention regardless of age: cyclosporine, mycophenolate mofetil, methotrexate, and azathioprine. This article reviews the use of these medications as well as several promising targeted therapies currently in development including dupilumab and apremilast. We briefly cover several other systemic interventions that have been studied in children with atopic dermatitis.