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What is Combination Therapy for AD?

What is Combination Therapy for AD?

Common treatment options for atopic dermatitis include topical corticosteroids, topical calcineurin inhibitors, emollients, systemic corticosteroids, immunomodulators, and more.

What is monotherapy?

When these treatment options are used on their own, the treatment regimen is considered a monotherapy. When an individual is utilizing a monotherapy treatment regimen, they are relying exclusively on that treatment option to provide relief from their symptoms. Because they are using only one therapy, it may be necessary to use a higher dosage of that treatment option, which could lead to undesirable side effects or an eventual plateau in effect. These issues may also impact an individual’s ability to adhere to their treatment plan, eventually leading to a worsening of symptoms. Instead of relying on one singular therapy, many individuals with AD, and their healthcare providers are turning to combination therapy instead.1-3

What is combination therapy?

Combination therapy involves the use of two or more treatment options at the same time. For AD, examples of combination therapy regimens may include systemic corticosteroids used with emollients, or immunomodulators used alongside topical corticosteroids. There are many different possibilities of combination therapy regimens for AD, and a growing body of research has arisen in recent years to determine their efficacies.

Why is combination therapy used?

Every treatment option has its own mechanism of action and potential for symptom relief. Additionally, one single treatment option may impact different individuals in different ways. For example, one individual may experience significant skin clearing and itch relief using a specific systemic corticosteroid, but another individual with AD may experience no relief or may experience side effects that are severe enough to want to discontinue treatment.

Varying interactions

In addition to this variability, when different treatment options are combined, they have a possibility of interacting and creating an entirely new outcome. For example, two medications may negatively impact each other and cause a reduction in symptom relief than either medication on its own, or may create undesirable side effects when combined. Conversely, two medications may impact each other in a positive way, and may provide a benefit greater than either one on their own. The potential for a positive interaction that increases symptom relief is the basis of why combination therapy is of interest to individuals with AD and their healthcare providers.

Safety and efficacy

In some cases, two or more treatment options may create a greater, positive effect on an individual with AD than one treatment alone, or than a different combination of treatment options. Since some treatment options have the possibility to cause adverse effects when combined, not all combinations are considered safe or effective. A healthcare provider can help outline different safe combinations of treatments to try that may provide more relief than any other monotherapy by itself that has been tried previously.

Decreasing dosage

Further, it’s possible that when combined, one treatment option may alleviate undesirable side effects of another treatment. Additionally, combining treatments may allow for an individual to decrease the dosage of one or more medications they are taking when used alongside other therapies. This is especially helpful in situations where a treatment option has serious side effects or could do damage to other structures in the body, as well as when a treatment option can only be utilized for a short period of time when taken in larger dosages.1-3

Common uses of combination therapy

Common situations in which combination therapy may be appropriate include:

  • When treatment with a singular therapy produces undesirable side effects or is ineffective at alleviating symptoms
  • When an individual cannot tolerate a full dosage of a treatment
  • During the transition from one treatment option to another
  • During periods of flare-ups or when symptoms increase in severity
  • When an individual has other comorbid or co-occurring conditions that may benefit from the use of an additional therapy1

What does the research say about combination therapy for AD?

As mentioned, research into the efficacy of different combination therapies for the treatment of AD is a growing field of study.

Dupilumab and topical corticosteroids

Of note, one recently published study investigated the efficacy of the immunomodulatory medication Dupilumab in combination with topical corticosteroids for the treatment of AD. The researchers concluded that Dupilumab taken once a week or once every two weeks in combination with topical corticosteroids improved AD and AD-related quality of life more than Dupilumab on its own as a monotherapy.4

Topical corticosteroids and calcineurin inhibitors and/or emollients

Other studies have investigated topical corticosteroids in combination with topical calcineurin inhibitors, emollients, or both, and have shown promising results thus far.3

Complementary medicine

Further studies have investigated the use of complementary medicine, such as herbal medicine, in combination with traditional atopic dermatitis treatment options like oral antihistamines.5

Other studies

One additional study investigated the use of subcutaneous allergen immunotherapy (SCIT) using house dust mite (HDM) extract in addition to treatment with cyclosporine in individuals with AD who were hypersensitive to HDM extract. Although cyclosporine can help reduce AD-related symptoms quickly and effectively, it has many potential side effects and can only be taken for 12 months at a time or less due to long-term safety concerns. SCIT involves slowly introducing the body to an allergen in very small amounts in order to decrease hypersensitivity to that allergen over time.

SCIT and cyclosporine

Some experts have theorized that treatment with SCIT may be an effective long-term option for AD, and combining SCIT with cyclosporine has been theorized to provide immediate relief as SCIT is ongoing, which may eventually allow an individual to taper off the dosage of cyclosporine when SCIT treatment is nearing completion. Although one study found this combination to be effective, more research is needed to further understand this potential pairing.6

Talk to your doctor!

As mentioned, although combination therapies may be more effective in some instances that monotherapies, it is important to check in with your healthcare provider to determine if a combination of treatment options is safe for you to try. Some treatment options may negatively impact one another, or may exacerbate other co-occurring conditions that you may have, so all potential combinations should be reviewed by a medical professional before they are tried.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The AtopicDermatitis.net team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. Cather JC, Crowley JJ. Use of biologic agents in combination with other therapies for the treatment of psoriasis. Am J Clin Dermatol. 2014; 15(6), 467-78. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4239825/. Accessed July 28, 2018.
  2. Norris DA. Mechanisms of action of topical therapies and the rationale for combination therapy. J Am Acad Dermatol. Jul 2005; 53(1 Suppl 1), S17-25.
  3. Walling HW. Swick BL. Update on the management of chronic eczema: New approaches and emerging treatment options. Clin Cosmet Investig Dermatol. 2010; 3, 99-116. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3047944/. Accessed July 28, 2018.
  4. de Bruin-Weller M. Thaci D, et al. Dupilumab with concomitant topical corticosteroid treatment in adults with atopic dermatitis with an inadequate response or intolerance to ciclosporin A or when this treatment is medically inadvisable: A placebo-controlled, randomized phase III clinical trial (LIBERTY AND CAFÈ). Br J Dermatol. May 2018; 178(5), 1083-1101.
  5. Yun Y, Son J, et al. Effectiveness and safety of combination treatment of herbal medicines and oral antihistamines for atopic dermatitis: A retrospective chart review. Integr Med Res. Mar 2017; 6(1), 19-25. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5395680/. Accessed July 28, 2018.
  6. Nahm DH, Kim ME. Treatment of severe atopic dermatitis with a combination of subcutaneous allergen immunotherapy and cyclosporin. Yonsei Med J. 1 Jan 2012; 53(1), 158-163. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3250339/. Accessed July 28, 2018.

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