Pharmacological management of atopic dermatitis in the elderly

ABSTRACT

Introduction

The prevalence of atopic dermatitis (AD) in geriatric populations of industrialized countries is currently estimated at 3-4% and continues to increase. AD is associated with significant morbidity, increased susceptibility to infection, and symptoms of pruritus and pain. Treatments may negatively affect elderly patients; thus, plans should be optimized for this population.

Areas covered

This review summarizes treatment options for AD in the elderly. A systematic review of the literature was conducted using the key terms atopic dermatitis, elderly, geriatric, systemic therapy, therapy, and topical therapy in PubMed. Searches yielded articles on skincare management and topical and systemic pharmacotherapies.

Expert opinion

Proper use of moisturizer is crucial in all patients with AD. Topical corticosteroids are commonly prescribed; however, they carry an increased risk of adverse events such as skin atrophy. Systemic corticosteroids should be avoided in elderly patients due to questionable efficacy and increased adverse events. Topical calcineurin inhibitors and crisaborole are similarly efficacious with an excellent safety profile. Cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil are systemic agents available for the treatment of refractory AD; however, insufficient data exist to indicate the superiority of any one agent. Dupilumab is a safe and efficacious injectable therapy in elderly patients.

KEYWORDS:

• Atopic dermatitis
• azathioprine
• corticosteroids
• crisaborole
• cyclosporine
• dupilumab
• methotrexate
• mycophenolate
• pimecrolimus
• tacrolimus
• topical calcineurin inhibitors
• topical corticosteroids

Article Highlights

• Elderly adults with AD have increased susceptibility to treatment side effects due to concomitant underlying comorbidities and physiologic changes requiring careful consideration and monitoring of therapies in comparison to younger patients.

• Treatment should follow a stepwise progression beginning with moisturizer use, then topical therapies, and finally, systemic therapies if needed.

• Proper skincare and use of moisturizers is a mainstay of AD treatment and should be optimized before considering pharmacological therapy.

• TCIs and crisaborole may be better tolerated topical treatments in the elderly due to the higher risk of AEs associated with TCS use in the elderly.

• Systemic corticosteroids should be avoided in elderly patients.

• Dupilumab is a safe and effective first-line therapy for moderate-to-severe AD in the elderly.

This box summarizes key points mentioned in the article.

Declaration of interest

S Feldman has received research, speaking and/or consulting support from Amgen Inc. Galderma, GlaxoSmithKline/Stiefel, Almirall, Leo Pharma, Boehringer Ingelheim, Mylan, Celgene, Pfizer, Valeant, AbbVie, Samsung, Janssen, Eli Lilly and Company, Menlo, Merck and Co., Novartis, Regeneron, Sanofi, Novan, Qurient, the National Biological Corporation, Caremark, Advance Medical, Sun Pharma, Suncare Research, Informa, UpToDate and the National Psoriasis Foundation. He is founder and majority owner of www.DrScore.com and founder and part owner of Causa Research. L Strowd has received grants and/or support from Galderma, Pfizer, Actelion, and Sanofi Regeneron. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer Disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript has not been funded.