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- Presentation
Treatment Considerations for Atopic Dermatitis in Special Populations
Description
The talk reviewed treatment considerations for atopic dermatitis in special populations, emphasizing that evidence is limited because many clinical trials exclude these patients. In pregnancy, disease course is variable, and undertreatment can harm both mother and fetus; phototherapy is preferred when available, PUVA should be avoided, cyclosporine remains a guideline-supported option in some regions, and biologics such as dupilumab have reassuring registry and case-report data, with placental transfer increasing in later trimesters. For lactation, most therapies are similar in approach, though cyclosporine and azathioprine have mixed breast milk data. The speaker noted that methotrexate, mycophenolate, and JAK inhibitors are generally avoided, with recommended preconception discontinuation for some agents. In infections, UVB phototherapy and biologics were generally viewed as safer choices across HIV, hepatitis, TB, and zoster, while traditional immunosuppressants and JAK inhibitors require more caution; vaccination and infection screening were highlighted, especially for zoster and TB before JAK inhibitors. In renal disease, UVB and biologics were considered safer, whereas cyclosporine and JAK inhibitors need dose adjustment and caution in impaired kidney function. For older adults, issues include polypharmacy, comorbidities, and reduced ability to monitor or self-administer treatment; biologics, especially dupilumab, have growing real-world evidence of safety and efficacy, while JAK inhibitors carry boxed warnings but may still be used selectively with careful risk assessment.
View moreConclusions
- Management of atopic dermatitis in pregnancy should balance medication risks against the harms of undertreatment, which can worsen quality of life, sleep, stress, and infection risk.
- UVB phototherapy is one of the safest and most broadly recommended options across special populations when it is accessible.
- Cyclosporine remains a commonly supported systemic option in pregnancy and some other special settings, but it requires careful monitoring for maternal toxicity and blood pressure effects.
- Methotrexate, mycophenolate, and JAK inhibitors are generally the least favored agents in pregnancy, lactation, and several infection-related settings because of reproductive and immunologic risk.
- Available biologic data are increasingly reassuring, especially for dupilumab, with no clear signal for major pregnancy, lactation, or infection-related harm in the limited evidence available.
- Placental transfer of biologics increases later in pregnancy, so timing of continuation or initiation matters, particularly in the third trimester and around newborn or preterm infants.
- In patients with HIV, hepatitis, TB, or zoster, biologics and phototherapy often appear safer than traditional immunosuppressives or JAK inhibitors, though evidence remains limited for many agents.
- For hepatitis and tuberculosis, infection screening and coordination with relevant specialists are important before starting higher-risk systemic therapies.
- JAK inhibitors require special caution in patients with renal impairment because dose adjustments are needed and severe kidney disease may limit use.
- Older adults can use newer therapies, but treatment choice should account for polypharmacy, functional limitations, renal function, and the need for monitoring.
- Real-world data in older adults are expanding and generally support acceptable safety and effectiveness for some biologics, especially dupilumab.
- For older adults on JAK inhibitors, short-term dermatology data are reassuring, but black-box concerns and thrombotic or cardiovascular risk still warrant individualized risk assessment.
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