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Management of severe refractory atopic dermatitis (eczema)

Jonathan M Spergel, MD, PhD, FAAAAI
Section Editors
Robert P Dellavalle, MD, PhD, MSPH
Moise L Levy, MD
Joseph Fowler, MD
Deputy Editor
Rosamaria Corona, MD, DSc


Atopic dermatitis is a common, chronic, inflammatory skin disorder characterized by the presence of pruritic eczematous dermatitis. In most patients, the disorder is managed with careful skin care practices, topical therapies for inflammation, and the elimination of exacerbating factors. Patients with severe disease that fails to improve with conventional therapy may benefit from phototherapy or systemic medications.

This topic reviews the causes and treatment of severe, refractory atopic dermatitis. The clinical manifestations, diagnosis, and conventional management of the disease and the role of allergy in atopic dermatitis are discussed separately. (See "Atopic dermatitis (eczema): Pathogenesis, clinical manifestations, and diagnosis" and "Treatment of atopic dermatitis (eczema)" and "Role of allergy in atopic dermatitis (eczema)".)


Most patients with atopic dermatitis have mild to moderate disease. However, a subpopulation of patients develops severe symptoms. Severe atopic dermatitis may be loosely described as the presence of widespread skin lesions or physically or emotionally disabling disease that significantly compromises a patient's quality of life (picture 1).

Clinical studies have utilized scales for defining the severity of atopic dermatitis, such as the Severity Scoring of Atopic Dermatitis (SCORAD) index and the Eczema Area and Severity Index (EASI) [1]. Although such scales are useful for standardizing the results of research studies, they are not routinely used in clinical practice. Patients with severe atopic dermatitis who do not respond to conventional therapy may be classified as having severe, refractory disease.


Prior to initiating second-line treatments for atopic dermatitis, clinicians must ensure that severe, refractory disease is not a result of the presence of an avoidable or treatable exacerbating factor. Circumstances that may contribute to severe or refractory atopic dermatitis include non-compliance with conventional therapy, secondary infection, hypersensitivity reactions to topical treatments, and exposure to triggers of disease flares.

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Literature review current through: Nov 2017. | This topic last updated: Feb 02, 2015.
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