Eczema in kids: Ciclosporin induces rapid response, methotrexate affords sustained disease control

In the treatment of children with atopic eczema, ciclosporin is linked to a more rapid response while methotrexate (MTX) is associated with sustained disease control following discontinuation, a study has found.

This multicentre, parallel group, assessor-blinded, pragmatic trial included 103 atopic eczema patients (mean age 10 years, 48 percent female) who were unresponsive to potent topical treatment. They were randomized to receive either oral ciclosporin (4 mg kg^–1 daily; n=52) or MTX (0.4 mg kg^–1 weekly; n=51) for 36 weeks and then followed up for 24 weeks off therapy.

Researchers assessed the change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and the time to having to restart systemic therapy following treatment cessation as coprimary endpoints. Secondary endpoints included the change in Eczema Area and Severity Index (EASI), Investigator Global Assessment (IGA) and Patient Orientated Eczema Measure (POEM), and frequency of patient-reported flares off therapy. Adverse events were also evaluated.

By 12 weeks, patients in the ciclosporin vs MTX group showed greater improvement in disease severity (mean difference in o-SCORAD change, –5.69, 97.5 percent confidence interval [CI], –10.81 to –0.57; p=0.01), with no significant difference in the number of patients needing to restart systemic therapy following treatment cessation (hazard ratio, 1.55, 97.5 percent CI, 0.77 to –3.10; p=0.16).

Furthermore, significantly more ciclosporin-treated patients achieved a 50-percent reduction in o-SCORAD by 12 weeks (48.1 percent vs 27.5 percent; odds ratio [OR], 2.60, 95 percent CI, 1.23–5.49; p=0.01).

While there was no between-group difference in o-SCORAD-50 at 36 weeks (OR, 0.93, 95 percent CI, 0.46–1.88; p=0.86), by 60 weeks, MTX proved superior (OR, 0.33, 95 percent CI, 0.13–0.85; p=0.02). The same was true for EASI, with no difference seen at 36 weeks (mean difference, 1.61, 95 percent CI, –0.72 to 3.94; p=0.17) and ciclosporin-treated patients showing poorer disease control after treatment cessation at week 60 (mean difference, 6.36, 95 percent CI, 3.31–9.41; p<0.001). Consistent results were seen using the IGA and POEM scores throughout the study.

Treatment with ciclosporin also led to more patient-reported flares off treatment (mean difference, 3.22, 95 percent CI, 0.42–6.01; p=0.03). Meanwhile, adverse events frequency was comparable between the treatment groups.