Guidelines for atopic dermatitis management: What is recommended and what is not
Most clinical guidelines recommend daily bathing in lukewarm water, followed by the application of moisturizers, in the treatment of atopic dermatitis (AD), according to an expert who presented at the 23rd Asian-Australasian Regional Conference of Dermatology (RCD 2018) held in Surabaya, Indonesia.
Dr. Agnes Heng, president of the Dermatological Society of Malaysia and a council member of the Asian Academy of Dermatology and Venereology, compared the different clinical guidelines used for the treatment of AD, which included those from Malaysia, Singapore, Taiwan, India, Korea, Japan, Hong Kong, Asia Pacific, Europe and the US.
“All guidelines encourage the avoidance of damaging, drying and irritating soaps with alkaline pH,” Heng said, adding that most guidelines also recommend applying moisturizers at least twice a day and preferably after bath while the skin is still moist.
Asia-Pacific, European and Korean guidelines recommend the application of 200–300 g/week of moisturizers to the whole body for an adult, she said.
“An ideal moisturizer should be safe, effective, inexpensive, and free of additives, fragrances, perfumes and other potentially sensitizing agents,” Heng added.
Topical pharmacotherapies, such as corticosteroids (TCS) and calcineurin inhibitors (TCI), are also endorsed as effective therapies for AD. In general, low-potency TCS are suggested for maintenance therapy, whereas intermediate and high-potency TCS are recommended for the acute control of AD.
“All guidelines recommend tailoring the strength of TCS based on location, severity, chronicity of eczema and age of the patients,” Heng said, adding that proactive, intermittent use of TCS as maintenance therapy (1–2 times/week) is suggested on areas that commonly flare (hotspots).
However, due to steroid-phobia, most guidelines urge clinicians to recognize and address patient fears of side effects associated with the use of TCS to improve adherence and to avoid undertreatment.
On the other hand, most guidelines recommend TCIs, including tacrolimus and pimecrolimus, for acute and chronic AD, along with maintenance, in both adults and children. In addition, all guidelines discuss the local side effects of TCI, such as burning, stinging and pruritus, and advise that patients be provided with this information when it is first prescribed.
For other topical therapies, phosphodiesterase 4 inhibitor and topical Janus kinase inhibitor are given passing mention in the American Academy of Dermatology (AAD), European, Malaysian and Korean guidelines, while antihistamines, capsaicin, cannabinoid receptor agonists, opioid receptor agonists and anaesthetics are discussed but not recommended in the AAD, European and Korean guidelines.
Systemic therapies (antihistamines, corticosteroids, cyclosporine, azathioprine, methotrexate, mycophenolate mofetil) are also discussed in some guidelines, but most agree that this kind of treatment may only be considered in moderate-to-severe cases of AD or as an alternative for patients who are unresponsive to topical therapy and should not be used for the long term.
Biologic agents, particularly dupilumab, are only mentioned in 2018 guidelines (Europe and Malaysia).
“Dupilumab is recommended as a disease-modifying drug for patients with moderate-to-severe AD, in whom topical treatment is not sufficient and other treatment is not advisable,” Heng said. “Dupilumab should be combined with daily emollients and may be combined with topical anti-inflammatory drugs as needed.”
Furthermore, adjunctive treatment, such as probiotics/prebiotics, essential free fatty acids, vitamin D, Chinese herbal medicine, acupuncture, homoeotherapy, allergen specific immunotherapy, autologous blood therapy, bioresonance, balneotherapy, topical oils and massage therapy, is not recommended.
Finally, Heng said that treatment adherence and poor quality of life (QoL) are key issues in patients with AD. Patient education interventions are needed to help patients and their families to better understand their disease and cope with treatment, potentially resulting in improved QoL and treatment adherence.
“Most guidelines discussed this in detail and recommend that educational intervention should be considered as part of management of AD. They advocate for multidisciplinary training programmes in addition to video interventions as a useful adjunct,” she said.
Clinical guidelines are “statements that include recommendations, intended to optimize patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options,” Heng explained.
Guidelines are a tool for making care more consistent, as well as close the gap between what clinicians do and what scientific evidence supports.