Atopic dermatitis can be a chronic disabling disorder with a significant impact on patients quality of life. Currently, we do have efficacious systemic therapies, especially for the short term, such as corticosteroids, ciclosporine and photo-therapy. Most of these therapies are conditioned on the long term, mainly due to security reasons. Therefore, we still need to develop new treatments which combine efficacy, safety and the possibility of maintenance therapy. In this scenario, the recently published study by Dr. Schram and co-workers deserves to be read in detail as it is the first randomized controlled trial comparing methotrexate and azathioprine in severe atopic eczema. Two potentially efficacious agents to treat atopic dermatitis but with little reported evidence to support this indication.
The authors designed a single-blind, parallel-group randomized controlled study enrolling 42 adult patients suffering from severe atopic eczema to be treated with methotrexate 10-22,5 mg/wk or azathioprine 1,5-2,5 mg/Kg/day during 12 weeks, and 12 weeks of follow-up. At the end of the treating period (week 12), patients receiving methotrexate had a mean relative reduction in the severity scoring of atopic dermatitis index of 42% (SD,18%) compared with 39% (SD, 25%) in the azathioprine group (P=0,52). At weeks 12 and 24 the impact both therapies had on patients quality of life and symptoms was similar.There were no statistically significant differences in the number and severity of adverse events between both groups.
The authors conclude that methotrexate and azathioprine can be considered as adequate alternatives for the treatment of severe atopic eczema in adults as they were both safe in the short term and they had both clinically relevant positive impact on the disease. Future studies with bigger numbers of patients and longer time of treatment and follow-up will help us to define the role these drugs can have in our every day management of patients suffering from atopic eczema.
A randomized trial of methotrexate versus azathioprine for severe atopic eczema. Schram ME, Roekevisch E, Leeflang MM, Bos JD, Schmitt J, Spuls PI. J Allergy Clin Immunol. 2011 Aug;128(2):353-9. PMID: 21514637
A randomized trial of methotrexate vs. azathioprine for severe atopic eczema: a critical appraisal. Patel AN, Langan SM, Batchelor JM. Br J Dermatol. 2012 Apr;166(4):701-3. PMID: 22452432