ATOPIC DERMATITIS clinical guidelines
American Academy of Dermatology
The guideline is made up of four sections each covering a range of topics related to diagnosis, assessment, safety, and efficacy of treatments for atopic dermatitis (AD).
There have been various attempts to develop tools to help streamline the diagnosis of AD such as the Hanifin and Rajka criteria. However, without any modification, these are not ideal for clinical practice and mostly used in clinical trials. A modified criteria tool has been developed and should be used to diagnose AD in adults and pediatrics.
If a patient is not responding to treatment, then the diagnosis of AD should be reassessed and other disorders (comorbidities) should be considered.
Allergic contact dermatitis may be both an alternative diagnosis to AD and/or an exacerbator of AD in some individuals.
There is currently no reliable biomarker that can distinguish the disease from other entities. The most commonly used biomarker is elevated total and/or allergen-specific serum IgE. Other biomarkers are being studied and may help serve as identifiers of AD.
Various clinical associations/comorbidities have been linked to AD, however, there is no guarantee or consensus that screening improves disease outcome. Most importantly clinicians should be aware of these associations.
Linked clinical associations/comorbidities include allergies, asthma, and allergic rhinitis/rhinoconjunctivitis. Others include sleep disturbance, depression, cancer, and obesity, among others.
There are various risk factors associated with AD development. However, only two have constantly been associated, and they are (1) family history of atopy and (2) loss of function mutations in the FLG gene. Other risk factors based on ethnicity, socioeconomic background, and diet, among others, have not been consistently linked to the development of AD.
Non-pharmacologic interventions such as the role of moisturizers and bathing practices to help with treatment, maintenance, and prevention of flares are discussed in this section.
Moisturizers: The application of moisturizers should be an integral part of the treatment of patients with AD. They are also important components of maintenance therapy and prevention of flares.
Bathing practices, including additives: Bathing is suggested in patients with AD as part of treatment and maintenance; however, there is no standard for the frequency or duration of bathing appropriate for those with AD. Moisturizers should be applied soon after bathing to improve skin hydration. Limited use of non-soap cleansers (that are neutral to low pH, hypoallergenic, and fragrance-free) is recommended, and there is no data to support the use of bath water additives (oils, emollients, etc.).
Wet-wrap therapy with or without topical corticosteroid can be recommended for patients with moderate to severe AD to decrease severity and water loss during flares.
Topical corticosteroids (TCS) are used on both adults and pediatrics for the management of AD. A variety of factors must be considered to choose the proper TCS for treatment, such as patient preference and age. No specific monitoring is required for side effects. However, based on patient risk factors and response some monitoring may be required. Patient education may be key to address misconceptions of TCS.
Topical calcineurin inhibitors (TCI) can be used for the treatment of acute and chronic AD as well as maintenance therapy in both adults and children. They can serve as a steroid-sparing treatment; however, careful considerations must be made before prescribing. Patient education regarding TCI for AD is crucial since there are some adverse effects they may experience. Concomitant use of TCS and TCI can be used to treat AD. No specific monitoring is required for TCI; however, based on individual patient risk factors it may be warranted.
Topical antimicrobials and antiseptics: Bleach baths with intranasal mupirocin have been shown to be beneficial for AD patients; however, they are not routinely recommended. This therapy is mostly for patients with clinical signs of secondary bacterial infection to help reduce disease severity. All other forms of antimicrobial and antiseptic therapies have not been shown to be clinically helpful for AD.
Topical antihistamines are not suggested for the treatment of AD due to the risk of absorption and contact dermatitis.
Other topical agents are currently being studied for their use in treating AD. However, no conclusive data is available.
Phototherapy is typically used as a treatment for both acute and chronic AD in pediatric and adult patients. NB-UVB is the most commonly used phototherapy due to its low-risk profile, efficacy, and availability. Phototherapy can be used as monotherapy or in combination with other topical therapies. However, caution must be taken due to drug interactions and increased risk of adverse effects.
Phototherapy can be used in children; however, additional factors such as their psychological perspective may need to be considered when administering therapy.
Various factors must be considered when prescribing systemic agents, such as previous therapy failure or contraindications, as well as quality of life and disease severity. When using systemic agents, the minimal effective dose should be used, because there is no optimal dosing, duration, or monitoring protocol due to the lack of data. Treatment is highly individualized and based on patient response, comorbidities, and history.
The following systemic therapies can be used off-label to treat AD. Some should only be considered as an alternative when other more commonly used off-label systemic therapies are not an option:
Cyclosporine: off-label use for AD
Azathioprine: off-label use for AD
Methotrexate: off-label use for AD
Mycophenolate Mofetil: alternative off-label use for AD
Interferon Gama: alternative use for AD
Systemic Steroids should be avoided when possible for the treatment of AD. They mainly serve for short-term bridge therapy to other systemic therapies or for acute severe exacerbations.
There is insufficient data to make proper recommendations for the use of the following systemic therapies for the treatment of AD:
Oral Calcineurin Inhibitors
Other Systemic Therapies (TNF-alpha inhibitors, IV immunoglobulin, theophylline, papaverine, or thymopentin)
The use of systemic antibiotics is not encouraged unless there is clinical evidence of bacterial infection or eczema herpeticum.
There is no data to support the use of oral antihistamines as a treatment of AD, they can be used to help with pruritus and some sedating antihistamines can help (short-term) with sleep loss due to AD.
Continued use of TCS or TCI after disease stabilization can help prevent relapse or flares.
Patient education is important to inform the patient about AD and can be done through educational programs, video training, or nurse-led workshops. Education should always be an adjunct to conventional therapy.
Overall, allergy testing without a history of allergies in AD patients is not supported since AD can be affected by other non-allergic factors such as diet and the environment. If a patient does have a history of allergies or signs of contact dermatitis then it may be helpful to test for allergies (food allergies, inhalant/aeroallergens, allergic contact dermatitis).
Dietary interventions based solely on food allergies are not supported due to AD being affected by different non-food allergy/diet-based factors.
In children < 5 years of age with persistent AD despite optimized treatment or history of reaction to certain foods can be considered for food allergy tests.
If a food avoidance diet is being undertaken, then it should be done with the assistance of a dietician.
The following dietary supplements are not supported by data for the treatment of AD:
Fish oils, primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, E, B12, or B6
Environmental modifications are not supported by the currently available data and more studies are needed.
Measures to avoid and reduce contact with house dust mites (HDM) may be helpful in patients with high sensitivity to HDM.
Modification of laundering techniques such a
s double rinsing or use of certain detergents and laundry products is not supported by the current data.
There is limited data supporting the use of certain clothing fabrics and fibers to help reduce irritation, further studies are needed.
Other allergen-based interventions such as immunotherapy or sublingual immunotherapy for the treatment of AD are not supported by the currently available data.
There is insufficient evidence to support the use of complementary alternative therapies for the treatment of AD such as the following: traditional Chinese medicine, acupuncture, aromatherapy, homeopathy, naturopathy, acupressure, autologous blood injections.