Comparative effectiveness and safety of phototherapy, cytotoxic agents, and biologics in adults with atopic dermatitis: real-world multicenter cohort data.

Abstract

Background: Real-world comparative evidence on systemic agents, phototherapy, and biologics for atopic dermatitis (AD) remains limited.

Objective: To compare 24-week effectiveness and safety of methotrexate (MTX), cyclosporine, narrowband ultraviolet B (NB-UVB) phototherapy, upadacitinib, and dupilumab in adults with AD.

Methods: In this multicenter retrospective cohort (N = 1000; 200 per monotherapy group) across Saudi Arabia, SCORAD was extracted at baseline and mapped to prespecified weeks 2, 6, 12, and 24. Confounding was addressed using a multinomial propensity score (baseline SCORAD, age, sex, nationality) with overlap weighting; balance was assessed using Max |SMD|. Longitudinal change from baseline (ΔSCORAD) was analyzed using overlap-weighted generalized estimating equations with a treatment-by-time interaction, reporting adjusted marginal mean ΔSCORAD (95% CI).

Results: Unadjusted 24-week improvement was highest with dupilumab (75.8%) and upadacitinib (74.1%) (p < 0.001). In overlap-weighted models, both were associated with the largest week-24 improvements (ΔSCORAD -27.04 and -26.68). NB-UVB and methotrexate were intermediate, whereas cyclosporine had smaller sustained improvement. Upadacitinib had the highest recorded adverse-event frequency (68.5%), whereas dupilumab had the lowest (9%).

Conclusion: Dupilumab and upadacitinib were associated with larger 24-week SCORAD improvements than conventional systemic therapies and NB-UVB within this stratified analytic cohort. Results are associative and may be affected by residual confounding.