{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,25]],"date-time":"2026-06-25T15:37:23Z","timestamp":1782401843544,"version":"3.54.5"},"reference-count":120,"publisher":"Oceanside Publications Inc.","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["allergy asthma proc"],"published-print":{"date-parts":[[2022,11,1]]},"abstract":"<jats:p><jats:bold>Background:<\/jats:bold>The treatment of chronic refractory moderate-to-severe atopic dermatitis (AD) has traditionally relied on broad-spectrum systemic anti-inflammatory agents. With the introduction of biologics and Janus kinase inhibitors (Jakinib), the step management of moderate-to-severe AD is rapidly changing; however, guidelines have yet to provide formal recommendations for how to best incorporate these agents into the treatment plan.<jats:bold>Objective:<\/jats:bold>To summarize the updated evidence-based medical treatment for AD, including a proposed position for biologics and Jakinibs in the treatment algorithm.<jats:bold>Methods:<\/jats:bold>A literature search of several medical literature data bases for guidelines, position papers, systematic reviews, and clinical trials from 2012 to 2022 on the treatment of moderate-to-severe AD was conducted to prepare this narrative review.<jats:bold>Results:<\/jats:bold>Emollients and topical corticosteroids are the mainstay for treating acute flares and for maintaining chronic control. Second-line topical agents include calcineurin inhibitors, e.g., tacrolimus and pimecrolimus; crisaborole; and ruxolitinib. For acute flares, cyclosporine is preferred over systemic corticosteroids. For chronic treatment, phototherapy should be considered before systemic anti-inflammatory agents. Of the traditional anti-inflammatory agents, cyclosporine is the first-line choice, with methotrexate and azathioprine equal secondary choices. Although abrocitinib may have better efficacy then dupilumab based on indirect comparisons, abrocitinib requires closer monitoring for adverse events. Based on package labeling, Jakinibs, e.g., abrocitinib and upadacitinib, should be used only after failure with other systemic agents, including biologics (e.g., dupilumab and tralokinumab). Biologics and Jakinibs should be considered before the traditional systemic anti-inflammatory agents.<jats:bold>Conclusion:<\/jats:bold>Clinicians should consider a modified step management for AD as they await the development of national and international guideline recommendations for how best to position the biologics and Jakinibs into the AD treatment algorithm.<\/jats:p>","DOI":"10.2500\/aap.2022.43.220076","type":"journal-article","created":{"date-parts":[[2022,11,6]],"date-time":"2022-11-06T04:30:51Z","timestamp":1667709051000},"page":"474-493","source":"Crossref","is-referenced-by-count":18,"title":["Treatment options for moderate to severe atopic dermatitis"],"prefix":"10.2500","volume":"43","author":[{"given":"Dana V.","family":"Wallace","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1355","reference":[{"key":"B1","article-title":"What are \u201cBiologics\u201d Questions and Answers","year":"2018"},{"key":"B2","article-title":"Overview of biologic agents and kinase inhibitors in the rheumatic diseases","author":"Burmester","journal-title":"UpToDate"},{"key":"B3","article-title":"Evaluation and management of severe refractory atopic dermatitis (eczema) in adults","author":"Berger","journal-title":"UpToDate"},{"key":"B4","first-page":"151","article-title":"Update \u201csystemic treatment of atopic dermatitis\u201d of the S2k-guideline on atopic dermatitis","volume":"19","author":"Werfel","year":"2021","journal-title":"J Dtsch Dermatol Ges"},{"key":"B5","doi-asserted-by":"crossref","first-page":"2717","DOI":"10.1111\/jdv.16892","article-title":"ETFAD\/EADV Eczema Task Force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children","volume":"34","author":"Wollenberg","year":"2020","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"B6","doi-asserted-by":"crossref","first-page":"850","DOI":"10.1111\/jdv.14888","article-title":"Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II","volume":"32","author":"Wollenberg","year":"2018","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"B7","doi-asserted-by":"crossref","first-page":"657","DOI":"10.1111\/jdv.14891","article-title":"Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I","volume":"32","author":"Wollenberg","year":"2018","journal-title":"J Eur Acad Dermatol Venereol"},{"key":"B8","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1016\/j.jaad.2014.03.030","article-title":"Guidelines of care for the management of atopic dermatitis: section 3. 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