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Alternative Options in the Absence of Contraindications

Methotrexate

Methotrexate has been used in the treatment of moderate-to-severe AD for many years.

The onset of action takes several weeks. Its prescription is off-label (hors AMM).

Recommended dose:

• Adults: The initial dose is 5 to 15 mg/week, with a possible increase up to a maximum dose of 25 mg/week in adults.
• Children: Used off-label: 0.4 mg/kg/week, not exceeding 25 mg/week.

Regarding safety, subcutaneous administration improves bioavailability and tolerance compared to the oral route. The concomitant prescription of folic acid helps reduce gastrointestinal AEs and those related to the treatment's mechanism of action.

Since methotrexate is teratogenic, the use of effective contraception is necessary for women of childbearing age and for men whose partners are women of childbearing age (see specific populations section).

Concomitant use of emollients, TCS, and TCIs is possible. Combination with phototherapy is possible on an occasional basis. Combination with cyclosporine is a relative contraindication.

Treatment with methotrexate (off-label)

• In adult patients with atopic dermatitis requiring systemic treatment.
• In children with atopic dermatitis requiring systemic treatment.

Narrow-band UVB Phototherapy

Phototherapy can be used in patients with moderate-to-severe AD that is resistant to topical treatments.

However, our current knowledge on the safety of phototherapy in AD is insufficient in the absence of randomized controlled trials or registries including large numbers of patients with prolonged follow-up.

In patients treated with immunosuppressants, particularly cyclosporine and azathioprine, phototherapy is not recommended due to the combined risk of skin cancers.

Therefore, monitoring of patients who have had repeated and prolonged treatment cycles is recommended, especially for patients with fair phototypes. A maximum of 200 to 250 sessions is usually advised.

Concomitant use of emollients, TCS, and TCIs with phototherapy is possible, but they must not be applied before a phototherapy session.

• Treatment with narrow-band UVB phototherapy for adult patients with moderate-to-severe atopic dermatitis, taking the phototype into account and avoiding repeated or prolonged treatments.
• Other types of phototherapy (balneophototherapy, broad-spectrum UVB, UVA) should be considered as second-line.
• PUVA therapy should only be used when other types of phototherapy are ineffective.
• Use of phototherapy (UVA1 and narrow-band UVB) in the management of pruritus in atopic dermatitis.
• Use of narrow-band UVB (NB-UVB) phototherapy in cases of local treatment failure in pre-adolescents and adolescents, taking the phototype into account and avoiding repeated or prolonged treatments.
• Do not use phototherapy, of any type, in patients with an increased risk of skin cancer (history of skin cancer, helioderma, immunosuppressive treatments).

➜ Table des matières

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