Tools of the Trade: Managing Atopic Dermatitis Itch in Adults

Itch is one of the most prevalent complaints in patients with atopic dermatitis (AD) and has a serious impact on patient quality of life. Despite the large number of available AD treatments, AD and its associated itch can be difficult to manage. Herein, we briefly review a therapeutic ladder for the treatment of AD itch¹ and provide a few tools of the trade based on the authors’ experiences to aid in managing patients with treatment-refractory itch.

A numerical rating scale of itch (0 to 10) can be used to stratify patients into mild (1 to 4), moderate (5 to 7), or severe (8 to 10) itch. Generally, topical therapies alone are used in mild to moderate AD itch and systemic agents are reserved for patients with moderate to severe itch. Topical therapies may include an over-the-counter ceramide moisturizer with pramoxine, mid-potency topical steroids, wet wrap treatment with mometosone or a silicon-based gel, or the novel topical phosphodiesterase inhibitor, crisaborole (Eucrisa). We find that crisaborole is particularly effective in patients with hand eczema. For severe itch with limited rash, compounded ketamine (5 to 10%), amitriptyline (5%), and lidocaine (5%) can act peripherally on neurons to reduce itch.
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Systemic agents targeting cytokines involved in itch (eg, dupilumab [Dupixent], janus kinase inhibitors [JAK]) and non-specific immunosuppressants (eg, cyclosporine, mycophenolate mofetil, methotrexate, and azathioprine [Azasan]) may be useful in the treatment of AD itch. Drugs targeting the neural system such as low-dose mirtazapine, kappa-opioid agonists, gabapentin, and neurokinin 1 inhibitors can reduce neural sensitization—a common phenomenon in atopic eczema itch—and improve pruritus. Dupilumab—a monoclonal antibody targeting IL-4 receptor alpha—has been reported to dramatically reduce itch in AD.² Methotrexate is especially useful in treating itch associated with nummular eczema and in older aged patients with AD.

For those patients with nocturnal itch, nightly low-dose mirtazapine (7.5 to 15 mg at night) can be used. In severe cases of intractable itch, the kappa-opioid agonist butorphanol (Stadol) (1 to 4 mg at night) can rapidly and significantly treat itch. Finally, preliminary results from ongoing studies appear to support the optimism surrounding the benefits of JAK inhibitors in AD. These agents may prove to be specific and effective treatments for AD and AD-associated itch.

Although a variety of other agents not discussed here may also be useful in the treatment of AD itch, we hope that the tools of the trade briefly described in this article will aid in the management of this challenging condition.

Mr Rosen is a medical student with the department of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine in Miami, FL.

Dr Yosipovitch is professor of dermatology and director of the Miami Itch Center at the University of Miami Miller School of Medicine in Miami, FL.