[Place of immunosuppressors in atopic dermatitis]

Use of immunosuppressors in the treatment of atopic dermatitis is an important innovation that reinforces the therapeutic arsenal in this chronic disease. Two such drugs are used topically for the treatment of atopic dermatitis. Tacrolimus exists in pommade form at a concentration of 0.1% for adults and 0.03% for children. Pimecrolimus, another calcineurine inhibitor with similar efficacy and tolerability, is not marketed in France. These products inhibit cytokine production by antigen-stimulated T lymphocytes. Their clinical efficacy has been demonstrated in many studies in the United States and Europe. They are particularly valuable for patients whose clinical course is marked by disease persistence and frequent flares, which would otherwise require almost continuous topical corticosteroid treatment. Topical calcineurine inhibitors may also have a significant benefit in patients with involvement of sensitive skin areas, such as around the eyes, face, neck and genital area, where systemic absorption and the risk of skin atrophy are particular concerns. The most frequent adverse effects are a local erythema-like reaction with burning and pruritus at the outset of treatment. No significant increase in bacterial or viral infections has been noted by comparison with control groups, and no systemic impact has been reported. However, these drugs should not be used in patients with a history of Kaposi-Juliusberg disease or in patients with herpes. Photoprotection measures must be respected. New trials with tacrolimus show that atopic lesions can be controlled by treating subclinical inflammation twice weekly between flares, thereby preventing flares and prolonging the flare-free interval. This new therapeutic approach is called proactive treatment. The efficacy of oral cyclosporine at 4-5 mg/kg/day in severe forms of atopic dermatitis is now well demonstrated. There is consistent evidence that oral cyclosporin is beneficial in patients whose disease is not adequately controlled by conventional topical therapies, leading to a significant improvement in health-related quality of life. Other immunosuppressors like methotrexate and some biologics (omalizumab, retuximab, etc.) show good efficacy during flares of severe forms, but larger comparative studies are needed before recommending these new treatments in severe atopic dermatitis.