Management Guidelines for Atopic Dermatitis CONSENSUS AND GUIDELINES ·September 25, 2014 TAKE-HOME MESSAGE Section 4 of the atopic dermatitis (AD) management guidelines recommends use of topical corticosteroids or calcineurin inhibitors two to three times per week after disease stabilization to reduce flares. Specific recommendations for adjunctive and complementary interventions are summarized, including the following: moisturizers designed to improve the barrier function of the skin should be used by all patients, food elimination diets are not recommended when based on food-allergy testing alone, and there is inconsistent to no evidence to recommend probiotics/prebiotics as well as many vitamins.These guidelines are useful for the aim of preventing flares and addressing patient questions about complementary therapies and approaches in AD. – Sarah Churton, MD 1Expert Comment Dermatology Wendy Smith Begolka Lawrence F Eichenfield Robert Sidbury A novel recommendation in the current Guidelines of Care for Atopic Dermatitis is the idea of proactive therapy. Atopic dermatitis (AD), or eczema, is a “waxing and waning” condition and convention has long held that when the skin waxes, or flares, treatment should be initiated typically using topical corticosteroids (TCS) or topical calcineurin inhibitors (TCIs), only to be suspended in favor of emollients alone when symptoms abate. This “reactive” approach is grounded in the reality that constant use of either TCS or TCI risks adverse effects and periodic breaks when symptoms quiesce is both logical and necessary. While this construct is perfectly adequate for many, some children flare so often that “breaks” from medication are not possible or appropriate. Multiple studies have now demonstrated that by proactively treating areas of known disease---eczema tends to recur predictably---several times weekly before waiting for disease to flare, symptom-free periods can be extended. The language of the recommendation is as follows: Table II Continue use of either topical corticosteroids (1-2 times/wk) or topical calcineurin inhibitors (2-3 times/wk) after disease stabilization, to previously involved skin, is recommended to reduce subsequent flares or relapses. This “ounce of prevention” may quite literally be worth a pound jar of cure as studies have shown proactive care can lengthen time to first flare or relapse, and decrease use of topical anti-inflammatory medications. Embedded in this approach is a desire to both improve efficacy and increase safety by minimizing use of either TCS or TCI. A related but separate idea would be alternating use of TCS and TCI rather than exclusive monotherapy as is the norm; this too decreases the likelihood of overusing either agent. Another concept explored in the Guidelines aspires to this same goal of medication minimization: bleach baths. The idea of adding sodium hypochlorite to the bath, akin to chlorine in a swimming pool (an analogy that can sometimes soothe skeptical parents) was conceived as a method to prevent recurrent staphylococcal superinfection in frequently afflicted atopic children. The blinded, controlled study did indeed prove this hypothesis true. The more surprising secondary outcome of this study was significant improvement in eczema severity everywhere but above the neck where subjects were not exposed to the bleach bath. This finding has led to widespread recommendation of twice weekly bleach baths as prevention not only of infection but of potential eczema flaring as well. ABSTRACT Atopic dermatitis is a common, chronic inflammatory dermatosis that can affect all age groups. This evidence-based guideline addresses important clinical questions that arise in its management. In this final section, treatments for flare prevention and adjunctive and complementary therapies and approaches are reviewed. Suggestions on use are given based on available evidence. Journal of the American Academy of DermatologyGuidelines of Care for the Management of Atopic Dermatitis: Section 4. Prevention of Disease Flares and Use of Adjunctive Therapies and ApproachesJ Am Acad Dermatol 2014 Sep 25;[EPub Ahead of Print], R Sidbury, WL Tom, JN Bergman, KD Cooper, RA Silverman, TG Berger, SL Chamlin, DE Cohen, KM Cordoro, DM Davis, SR Feldman, JM Hanifin, A Krol, DJ Margolis, AS Paller, K Schwarzenberger, EL Simpson, HC Williams, CA Elmets, J Block, CG Harrod, WS Begolka, LF Eichenfield
Posted on: Sat, 18 Oct 2014 07:43:33 +0000
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