What are the guideline sources, guidelines and references for Atopic dermatitis ?
Guideline sources The following summarized guidelines for the evaluation and management of atopic dermatitis are prepared by our editorial team based on guidelines from the European Dermatology Forum (EDF 2022), the European Academy of Allergy and Clinical Immunology (EAACI 2021), the European Academy of Dermatology and Venereology (EADV/ETFAD 2020), the European Academy of Dermatology and Venereology (EADV/UEMS/EFA/GA LEN/ETFAD/EDF/EAACI/ESDaP/ESPD 2018), the European Academy of Dermatology and Venereology (EADV/UEMS/EFA/ETFAD/EDF/EAACI/ESDaP/ESPD 2018), and the American Academy of Dermatology (AAD 2014). 1 2 3 4 5 6 7 8 9 10 11 11 11 12 Definition Atopic dermatitis, also known as atopic eczema, is a chronic relapsing inflammatory skin condition characterized by intense itching. 11 Epidemiology Atopic dermatitis is caused by a complex interaction between defects in skin barrier function (caused by mutations in filaggrin gene), immune dysregulation, and environmental and infectious https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 1/12 6/23/23, 3:13 AM Atopic dermatitis Pathway agents (S. aureus). 12 Disease course Skin barrier dysfunction and immune dysfunction results in atopic dermatitis, which causes clinical phases of acute atopic dermatitis (vesicular, weeping, crusting eruption), subacute atopic dermatitis (dry, scaly, erythematous papules and plaques), and chronic atopic dermatitis (lichenification, thickening, from repeated scratching). Atopic dermatitis precedes the development of food allergies, asthma, and allergic rhinitis. The disease decreases productivity and quality of life. 11 Prognosis and risk of recurrence Atopic dermatitis is not associated with an increase in mortality. 11 Guidelines 1. Classification and risk stratification Severity grading: do not use available disease severity or patient quality of life measurement scales in routine clinical practice in the management of patients with atopic dermatitis. D 2. Diagnostic investigations Clinical history: Assess for environmental and food allergies as part of the initial evaluation of patients with atopic dermatitis. B Assess for symptoms of itch, sleep disturbance, impact on daily activity, persistence of disease, and use currently available disease severity scales when practical. B Biomarkers: insufficient evidence to recommend any specific biomarker for diagnosis and/or assessment of disease severity in patients with presumed atopic dermatitis. I Allergy testing: As per EADV 2020 guidelines: Obtain an allergy workup in patients with moderate-to-severe atopic dermatitis, including serum IgE, skin prick tests and patch tests for contact sensitization to ingredients of emollients and topical anti-inflammatory agents, depending on the individual history. Consider obtaining allergy work-up in patients with mild atopic dermatitis depending on clinical suspicion. E Consider setting a low threshold for obtaining patch tests with a standard series and components of topical treatment preparations in patients with atopic dermatitis. Obtain patch testing in patients with recalcitrant disease, atypical localization or aggravation without known cause, especially when systemic intervention is considered. E As per AAD 2014 guidelines, avoid obtaining allergy testing in patients without clinical features suggestive of allergy (such as hives or urticaria). D https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 2/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Show 2 more Specialized tests: consider obtaining skin biopsy specimens or other tests (e.g., serum IgE, potassium hydroxide preparation, patch testing, and/or genetic testing) to rule out other or associated skin conditions. C Screening for associated conditions: assess for conditions associated with atopic dermatitis, such as rhinitis/rhinoconjunctivitis, asthma, food allergy, sleep disturbance, depression, and other neuropsychiatric conditions, and discuss them with the patient as part of the treatment plan when appropriate. B 3. Medical management General principles: As per EDF 2022 guidelines: Ensure shared decision-making by discussing the patient's beliefs, lifestyle, and preferences when deciding on the treatment plan. A Ensure multidisciplinary treatment approach in patients with comorbidities. A As per AAD 2014 guidelines, consider an integrated, multidisciplinary approach to care for patients with atopic dermatitis. C Topical corticosteroids: As per EADV 2020 guidelines: Offer topical corticosteroids according to standard guidelines in combination with many other treatment modalities including patient education. E Offer proactive therapy with topical corticosteroids in patients with moderate-to-severe atopic dermatitis. E As per EAACI 2018 guidelines, offer topical corticosteroids (with an improved risk/benefit ratio) in patients with atopic dermatitis, especially in the acute phase. B Show 3 more As per AAD 2014 guidelines, initiate topical corticosteroids in patients with atopic dermatitis who have failed to respond to good skin care and regular use of emollients alone. A Show 3 more Topical calcineurin inhibitors: As per EADV 2020 guidelines: Offer topical calcineurin inhibitors as first-line therapy for delicate body areas in patients with atopic dermatitis, with preference for pimecrolimus in mild disease, and for tacrolimus in moderate-to-severe disease, and for long-term topical treatment. E Offer proactive therapy with topical calcineurin inhibitors in patients with moderate-to-severe atopic dermatitis. E As per EAACI 2018 guidelines, offer topical calcineurin inhibitors in patients with atopic dermatitis. B https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 3/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Show 4 more As per AAD 2014 guidelines, use topical calcineurin inhibitors, applied to actively affected areas, as a steroid-sparing agent for the initial treatment of atopic dermatitis. A Show 2 more Topical antimicrobials/antiseptics: As per EADV 2020 guidelines, consider offering topical antiseptic drugs and antiseptic baths in addition to an adequate anti-inflammatory treatment with topical corticosteroids and topical calcineurin inhibitors, if clinical signs of strong colonization or bacterial superinfection are present. E Show 3 more As per EAACI 2018 guidelines, do not use long-term topical antibiotics due to the risk of increasing resistances and sensitizations. D Show 2 more As per AAD 2014 guidelines: Consider using bleach baths and intranasal mupirocin to reduce disease severity in patients with moderate-to-severe atopic dermatitis and clinical signs of secondary bacterial infection. C Avoid using any other topical antistaphylococcal treatment in patients with atopic dermatitis. D Topical antihistamines: avoid using topical antihistamines for the treatment of patients with atopic dermatitis, due to the risk of absorption and of contact dermatitis. D Systemic immunomodulatory agents: As per EDF 2022 guidelines, offer any of the following in patients with atopic dermatitis being candidates for systemic treatment: cyclosporin baricitinib upadacitinib. A Show 5 more As per EADV 2020 guidelines, offer classical immunosuppressive therapy with cyclosporine A, methotrexate, mycophenolate mofetil or azathioprine only if topical treatment is not an option. Take into account all relevant patient- and drug-related factors including the patient's comorbidity, expected onset of efficacy, planed duration of treatment and licensing status of the drug when choosing an immunosuppressive agent. E As per EAACI 2018 guidelines, consider offering cyclosporine (for up to 2 years with a continuous regimen) in adult patients with chronic severe atopic dermatitis. Obtain careful monitoring for potential severe side effects. B Show 21 more As per AAD 2014 guidelines, offer systemic immunomodulatory agents in patients with atopic dermatitis in whom optimized topical regimens and/or phototherapy do not adequately control the signs and symptoms of disease. https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 4/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Show 4 more Systemic biologic agents: As per EDF 2022 guidelines: Offer any of the following in patients with atopic dermatitis being candidates for systemic treatment: dupilumab tralokinumab. A Insufficient evidence to support the use of omalizumab in patients with atopic dermatitis. I As per EAACI 2021 guidelines, offer dupilumab to reduce disease activity, rescue and background medication, and improve quality of life in adult and 12-17 years old pediatric patients with uncontrolled atopic dermatitis. A Show 12 more As per EADV 2020 guidelines, offer dupilumab for the treatment of 12 years old patients with moderate-to-severe atopic dermatitis, being candidates for systemic therapy. E As per ETFAD 2018 guidelines, offer dupilumab as a disease-modifying drug in patients with moderate-to-severe atopic dermatitis, if topical treatment is not sufficient and other systemic treatment is not advisable. A Show 3 more Systemic corticosteroids: As per EDF 2022 guidelines: Consider offering systemic corticosteroids only as rescue therapy for acute flares in patients with atopic dermatitis. C Do not use systemic corticosteroids for long term in patients with atopic dermatitis. D As per EAACI 2018 guidelines: Consider offering short-term (up to 1 week) oral corticosteroids for the treatment of an acute flare in exceptional cases of atopic dermatitis. Restrict its use, largely limited to adult patients with severe atopic dermatitis. C Adjust the daily dose of corticosteroids not exceeding 0.5 mg/kg body weight. Do not use oral corticosteroids for long-term. B As per AAD 2014 guidelines, avoid using systemic corticosteroids, if possible, for the treatment of patients with atopic dermatitis. Reserve corticosteroids exclusively for acute, severe exacerbations and as a short-term bridge therapy to other systemic, corticosteroid-sparing therapy. D Systemic antimicrobials: As per EAACI 2018 guidelines: Consider administering a short course of systemic antibiotics, such as cephalosporin, in patients with clinically infected with S. aureus. C Consider offering topical or systemic antifungal therapy in patients with 'head and neck' variant of atopic dermatitis or with demonstrated IgE sensitization to Malassezia species. C https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 5/12 6/23/23, 3:13 AM Atopic dermatitis Pathway As per AAD 2014 guidelines, administer systemic antiviral agents for the treatment of eczema herpeticum. B Show 2 more Systemic antihistamines: Avoid using non-sedating antihistamines as a routine treatment for atopic dermatitis in the absence of urticaria or other atopic conditions such as rhinoconjunctivitis. D Consider short-term, intermittent use of sedating antihistamines in patients with insomnia secondary to symptoms of itch, but avoid substituting them for management of atopic dermatitis with topical therapies. C Management of pruritus: As per EADV 2020 guidelines, do not use first- or second-generation H1RAs for the treatment of pruritus in patients with atopic dermatitis. D Show 2 more As per EAACI 2018 guidelines, offer topical corticosteroids to control pruritus in the initial phase of atopic dermatitis exacerbation. A Show 9 more As per AAD 2018 guidelines, consider offering short-term, intermittent sedating antihistamines in the setting of sleep loss secondary to pruritus. C Allergen immunotherapy: As per EADV 2020 guidelines: Do not offer allergen immunotherapy as a general treatment option in patients with atopic dermatitis. D Consider offering allergen immunotherapy in selected patients with house dust mite, birch or grass pollen sensitization, having severe atopic dermatitis and a history of clinical exacerbation after exposure to the causative allergen or a positive corresponding atopy patch test. E As per EAACI 2018 guidelines: Do not offer allergen-specific immunotherapy as a general treatment option in patients with atopic dermatitis. D Consider offering allergen-specific immunotherapy in selected patients with house dust mite, birch or grass pollen sensitization, having severe atopic dermatitis, and a history of clinical exacerbation after exposure to the causative allergen or a positive corresponding atopy patch test. C As per AAD 2014 guidelines, avoid using sublingual immunotherapy or injection immunotherapy to treat atopic dermatitis in the general atopic dermatitis population. D 4. Nonpharmacologic interventions Moisturizers and emollients: https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 6/12 6/23/23, 3:13 AM Atopic dermatitis Pathway As per EDF 2022 guidelines, consider advising the use of body care products (for example, gentle cleansers) not containing potent irritants or relevant allergens in patients with atopic dermatitis. C Show 4 more As per EADV 2020 guidelines, advise using liberal amounts of emollients daily, at least 30 g/day or 1 kg/month for an adult, preferentially applied in a 'soak-and-seal' technique. E As per EAACI 2018 guidelines, advise using emollients in adequate amounts, liberally and frequently, in a minimum amount of 250 g per week for adults. B Show 2 more As per EAACI 2018 guidelines, consider offering topical application of unsaturated fatty acids as an ingredient in emollients in selected cases. C As per AAD 2014 guidelines: Advise using moisturizers as an integral part of the treatment in patients with atopic dermatitis, as there is strong evidence that their use can reduce disease severity and the need for pharmacologic intervention. A Advise using a limited amount of non-soap cleansers that are neutral to low pH, hypoallergenic, and fragrance-free. B Bathing: As per EDF 2022 guidelines, advise gentle cleansing and bathing procedures in patients with atopic dermatitis, especially in acutely inflamed or superinfected skin. A Show 2 more As per EADV 2020 guidelines, advise regular bathing or showering in warm but not hot water about 2-7 times per week with very mild surfactant and emollient-based wash products in a 'soak-and-seal' approach. E As per EAACI 2018 guidelines, consider adding antiseptics such as sodium hypochlorite to the bathwater in patients with atopic dermatitis. B Advise using emollient bath oils and soap substitutes. C As per AAD 2014 guidelines, consider advising bathing in patients with atopic dermatitis as part of initial and maintenance treatment. Recognize that there is no standard for the frequency or duration of bathing appropriate for patients with atopic dermatitis. C Show 2 more Clothing and laundering: As per EADV 2020 guidelines, consider advising high-quality silver garments in patients with atopic dermatitis tending to strong colonization or infection with S. aureus. E As per AAD 2014 guidelines: Insufficient evidence to support the use of specialized clothing fabrics to treat atopic dermatitis. I Insufficient evidence to recommend the use of specific laundering techniques (such as double rinsing), detergents, or other laundry products for atopic dermatitis treatment. I https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 7/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Wet-wrap therapy: As per EADV 2020 guidelines, offer wet-wrap therapy in patients with atopic dermatitis in flare, or with acute, oozing and erosive lesions. E As per AAD 2014 guidelines, consider offering wet-wrap therapy, with or without a topical corticosteroid, in patients with moderate-to-severe atopic dermatitis, in order to decrease disease severity and water loss during flares. C Allergen avoidance: advise avoiding pollen exposure during the pollen season. B Show 2 more House dust mite covers: consider house dust mite covers to treat patients with atopic dermatitis who are sensitized to dust mites, based on limited evidence. C Food elimination diets: As per EADV 2020 guidelines, advise an elimination diet for atopic dermatitis based on a reliable history, rather than on type I sensitization detected by blood or skin prick tests, followed by elimination and reintroduction of suspected food or an oral food challenge, if this is feasible. E As per EAACI 2018 guidelines, offer a therapeutic diet eliminating foods that elicitated clinical early or late reactions upon controlled oral provocation tests in patients with moderate-to-severe atopic dermatitis. B As per AAD 2014 guidelines, avoid food elimination diets based solely on the findings of food allergy test results for the management of atopic dermatitis. D Dietary supplements: As per EADV 2020 guidelines, do not offer vitamin D supplementation for the treatment of patients with atopic dermatitis. D As per EAACI 2018 guidelines: Do not offer supplementation of unsaturated fatty acids for the treatment of atopic dermatitis. D Insufficient evidence to recommend vitamin supplementation for routine use in patients with atopic dermatitis. I As per AAD 2014 guidelines, insufficient evidence to support the use of fish oils, evening primrose oil, borage oil, multivitamin supplements, zinc, vitamin D, vitamin E, vitamin B12, or vitamin B6 for the treatment of atopic dermatitis. I Probiotics: As per EADV 2020 guidelines, do not offer probiotics for the treatment of patients with atopic dermatitis. D As per AAD 2014 guidelines, avoid probiotics/prebiotics to treat patients with established atopic dermatitis because of inconsistent evidence for effectiveness. D Psychosocial interventions: offer psychosomatic counseling, psychotherapeutical approaches, behavioral therapy techniques, autogenic training, relaxation techniques, psychological and psychosomatic interventions in selected patients with atopic dermatitis. A https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 8/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Alternative and complementary therapies: As per EADV 2020 guidelines, do not offer complementary medicine for the treatment of patients with atopic dermatitis. D As per EAACI 2018 guidelines, consider offering thermal spring water balneotherapy in patients with mild-to-moderate atopic dermatitis. C Show 2 more As per AAD 2014 guidelines, insufficient evidence to recommend the following therapies for the treatment of patients with atopic dermatitis: massage therapy I chinese herbal therapy I aromatherapy I naturopathy I hypnotherapy I acupressure I autologous blood injections. I 5. Therapeutic procedures Phototherapy: As per EADV 2020 guidelines, offer concomitant narrowband UV B or medium-dose UV A in combination with topical corticosteroids or selected systemic therapy for the treatment of patients with atopic dermatitis. E As per EAACI 2018 guidelines, offer medium-dose UV A1 and narrowband UV B for the treatment of adult patients with atopic dermatitis. B Show 5 more As per AAD 2014 guidelines, provide phototherapy as a second-line treatment, in patients with atopic dermatitis who have failed of first-line treatment with emollients, topical steroids, and topical calcineurin inhibitors. B Show 3 more Immunoadsorption: consider offering immunoadsorption in patients with severe atopic dermatitis and high serum IgE levels, if the technology is available. C 6. Patient education General counseling: Educate patients/caregivers in lay language about treating and managing their own condition. A Provide patients/caregivers adequate knowledge, skills, resources, and support for the treatment of atopic dermatitis at home and coping with its impact on life. A https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 9/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Occupational counseling: Develop and optimize preventive strategies to reduce the incidence of occupational dermatitis in patients with atopic dermatitis. E Advise patients with atopic dermatitis early on occupational aspects of their disease and suitable career choices. E Educational programs: As per EADV 2020 guidelines: Offer multimodal education programs to increase coping behavior in patients with atopic dermatitis. Offer relaxation and habit-reversal techniques as a complementary treatment in patients with atopic dermatitis. E Advise participation in a therapeutic education program for atopic dermatitis in all patients with moderate-to-severe atopic dermatitis. E As per EAACI 2018 guidelines, offer patient education programs for atopic dermatitis as an adjunct to conventional therapy in pediatric and adult patients. A As per AAD 2014 guidelines, offer educational programs and "eczema schools" as an adjunct to the conventional therapy of atopic dermatitis. A Counseling on corticosteroids: address patient fears of side effects associated with the use of topical corticosteroids for atopic dermatitis, in order to improve adherence and avoid under- treatment. B Counseling on calcineurin inhibitors: Inform patients of the theoretical risk of cutaneous viral infections with calcineurin inhibitor therapy, although no consistent increases in the prevalence of such viral infections have been documented with continuous or intermittent use of topical calcineurin inhibitors for up to 5 years. B Discuss the black box warning on the use of topical calcineurin inhibitors (stating that the treatments were linked in postmarketing reports with cancer-related adverse events, including lymphoma and skin malignancies) with patients in whom calcineurin inhibitors are being considered. B 7. Preventative measures Routine immunizations: As per EADV 2020 guidelines, follow all regional vaccination programs including the VZV vaccination as recommended. E Show 2 more As per EAACI 2018 guidelines, provide vaccinations in all pediatric patients diagnosed with atopic dermatitis according to the national vaccination plan. B As per EAACI 2018 guidelines: https://web.pathway.md/diseases/rec9qBSnBFgZQE6nw 10/12 6/23/23, 3:13 AM Atopic dermatitis Pathway Offer vaccination against VZV in pediatric patients with atopic dermatitis. Encourage parents of atopic children to fully immunize their children. B Initiate systemic antiviral therapy such as systemic aciclovir without delay for the treatment of patients with eczema herpeticum. B Primary prevention: advise exclusive breast milk feeding until 4 months of age for primary prevention of food allergy-associated atopic dermatitis. B Show 3 more 8. Follow-up and surveillance Follow-up: avoid routine monitoring of IgE levels for the assessment of disease severity. D Show 2 more References 1. A Wollenberg, S Barbarot, T Bieber et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part I. J Eur Acad Dermatol Venereol. 2018 May;32 5 657 682. Open 2. A Wollenberg, M Kinberger, B Arents et al. European guideline EuroGuiDerm) on atopic eczema - part II non-systemic treatments and treatment recommendations for special AE patient populations. J Eur Acad Dermatol Venereol. 2022 Sep 3. Open 3. Eichenfield LF, Tom WL, Chamlin SL et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb;70 2 338 51. Open 4. A Wollenberg, S Christen-Z ch, A Taieb et al. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children. J Eur Acad Dermatol Venereol. 2020 Dec;34 12 2717 2744. Open 5. A Wollenberg, S Barbarot, T Bieber et al. Consensus-based European guidelines for treatment of atopic eczema (atopic dermatitis) in adults and children: part II. J Eur Acad Dermatol Venereol. 2018 Jun;32 6 850 878. Open 6. Sidbury R, Tom WL, Bergman JN et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71 6 1218 33. Open 7. Sidbury R, Davis DM, Cohen DE et al. Guidelines of care for the management of atopic dermatitis: section 3. Management and treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71 2 327 49. Open 8. Ioana Agache, Cezmi A Akdis, Mubeccel Akdis et al. EAACI Biologicals Guidelines-dupilumab for children and adults with moderate-to-severe atopic dermatitis. Allergy. 2021 Apr;76 4 988 1009. Open 9. A Wollenberg, M Kinberger, B Arents et al. 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