American academy of dermatology's clinical guideline

1. Treatment of Atopic
Dermatitis
RENNU PRIAKSHAN VIVEGANANDARAJAH
GROUP 14, 4th COURSE

2. • Atopic dermatitis is a chronic, pruritic inflammatory skin disease that
occurs most frequently in children, but also affects many adults. It
follows a relapsing course. AD is often associated with elevated
serum immunoglobulin (IgE) levels and a personal or family history of
type I allergies, allergic rhinitis, and asthma. Atopic eczema is
synonymous with AD.
• The often protracted nature of AD necessitates setting several long-
term treatment goals: prevention of continued outbreaks,
management of co-morbidities and secondary complications that
arise, and minimizing adverse effects while trying to maximize
positive outcomes.
• Before treating use tests to diagnose and scales and indexes like
SCORAD to asses the severity

3. According to the American academy of dermatology
clinical guide lines, there are three main groups of
treatment
Topical therapy
Disease flares and
adjunctive therapy
Phototherapy and
systemic agent
1.Non pharmacologic
interventions
2.Topical corticosteroids
3.Topical Calcineurin
inhibitors
4.Topical antimicrobial
and antiseptics
5.Topical antihistamines
1.Phototherapy
2.Systemic
immunomodulatory
agents
3.Systemic
antimicrobials
4Systemic
antihistamines
1.Prevention of flares
2.Educational
interventions
3.Coexisting allergic
disease and allergy
testing
4.Dietary interventions
5.Environmental
6.modifications

4. 1.Non pharmacologic interventions
• The application of moisturizers should be an integral part of the
treatment of patients with AD as there is strong evidence that their use
can reduce disease severity and the need for pharmacologic
intervention.
• Bathing is suggested for 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 in patients with AD.
• Limited use of non soap cleansers (that are neutral to low pH,
hypoallergenic, and fragrance free) is recommended.
• Use of wet-wrap therapy with or without a topical corticosteroid can be
recommended for patients with moderate to severe AD to decrease
disease severity and water loss during flares.

5. 2.Topical Corticosteroids
• A variety of factors should be considered when choosing a
particular topical corticosteroid for the treatment of AD,
including patient age, areas of the body to which the
medication will be applied, and other patient factors such as
degree of xerosis, patient preference, and cost of
medication.
• TCS are grouped into 7 classes, from very low/ lowest
potency (VII) to very high potency (I), based on
vasoconstriction assays.

6. Class Drug Dosage Form(s) Strength (%)
I Very high
potency
Augmented
betamethasone
dipropionate
Ointment 0.05
II High Potency Amcinonide Cream, lotion,
ointment
0.1
III-IV. Medium
Potency
Fluocinolone
acetonide
Cream, ointment 0.025
V Lower-Medium
Potency
Hydrocortisone
butyrate
Cream, ointment,
solution
0.1
VI Low Potency Alclometasone
dipropionate
Cream, ointment 0.05
VII Hydrocortisone Cream, lotion,
ointment, solution
0.25, 0.5, 1

7. TCI are recommended and effective for acute and chronic treatment, along with maintenance, in
both adults and children with AD, and are particularly useful in selected clinical situation
Clinical situations in which topical calcineurin inhibitors may be preferable to topical steroids
Recalcitrance to steroids
Sensitive areas (e.g., face, anogenital, skin folds)
Steroid-induced atrophy
Long-term uninterrupted topical steroid use
Pimecrolimus cream and tacrolimus
4.Topical antimicrobial and antiseptics
In patients with moderate to severe AD and clinical signs of secondary bacterial infection, bleach baths and
intranasal mupirocin may be recommended to reduce disease severity.
5. The use of topical antihistamines for the treatment of patients with atopic
dermatitis is not recommended because of the risk of absorption and of
.
3.Topical Calcineurin inhibitors

8. 6. Phototherapy
1.Phototherapy is a second line treatment, after failure of first-line treatment (emollients,
topical steroids, and topical calcineurin inhibitors).
2.Phototherapy can be used as maintenance therapy in patients with chronic disease.
3Phototherapy treatment of all forms should be under the guidance and ongoing
supervision of a physician knowledgeable in phototherapy techniques.
4.The light modality chosen should be guided by factors such as availability, cost,
patient skin type, skin cancer history, patient use of photosensitizing medications, etc.
5.The dosing and scheduling of light should be based upon minimal erythema dose
(MED) and/or Fitzpatrick skin type.

9. 7. Systemic immunomodulatory agents
Systemic immunomodulatory agents are indicated for the subset of adult and pediatric patients
in whom optimized topical regimens and/or phototherapy do not adequately control the signs
and symptoms of disease.
Systemic immunomodulatory agents are indicated when the patient’s skin disease has
significant negative physical, emotional, or social impact.
All immunomodulatory agents should be adjusted to the minimal effective dose once response
is attained and sustained. Adjunctive therapies should be continued in order to use the lowest
dose and duration of systemic agent possible.
Insufficient data exists to firmly recommend optimal dosing, duration of therapy, and precise
monitoring protocols for any systemic immunomodulation medication.
Treatment decisions should be based on each individual patient's AD status (current and
historical), comorbidities, and preferences.
Cyclosporine is effective and recommended as a treatment option for patients with AD
refractory to conventional topical treatment.

10.  The use of systemic antibiotics in the treatment of non-infected AD is not recommended
 Systemic antibiotics are appropriate and can be recommended for use in patients with clinical
evidence of bacterial infections in addition to standard and appropriate treatments for AD
disease itself (which may include the concurrent use of topical corticosteroids).
 Systemic antiviral agents should be used for the treatment of eczema herpeticum.
9. Systemic Antihistamines
 There is insufficient evidence to recommend the general use of antihistamines as part of the
treatment of atopic dermatitis.
 Short-term, intermittent use of sedating antihistamines may be beneficial in the setting of
sleep loss secondary to itch, but should not be substituted for management of atopic
dermatitis with topical therapies.
8. Systemic antibiotics

11. 10. Educational Interventions
 Educational programs (i.e., training programs and ‘‘eczema schools’’) are recommended as
an adjunct to the conventional therapy of atopic dermatitis.
 Video interventions can be recommended as an adjunct to conventional therapy.
 Eczema workshops and nurse-led programs may be useful as an adjunct to conventional
therapy.
11. Coexisting Allergy diseases and their
management
 Atopic dermatitis patients have an increased rate of environmental and food allergies, and
physicians should assess for these conditions during history taking. If significant concerns
for allergy are identified (ie, hives, urticaria, etc) assessment can be undertaken. Allergy
testing independent of history is not recommended.
 Patch testing should be considered in patients with atopic dermatitis who have
persistent/recalcitrant disease and/or a history or physical examination findings consistent
with allergic contact dermatitis.

12.  Food elimination diets based solely on the findings of food allergy, test results are not recommended
for the management of AD.
 If a patient has a true immunoglobulin E-mediated allergy, he or she should practice avoidance to
prevent potential serious health sequelae.
 Children less than 5 years of age with moderate to severe AD should be considered for food allergy
evaluation for milk, egg, peanut, wheat, and soy if at least 1 of the following is met: (A) persistent AD
in spite of optimized treatment or (B) having a reliable history of immediate reaction after ingestion of
a specific food.
 The use of probiotics/prebiotics for the treatment of patients with established AD is not
recommended because of inconsistent evidence.
 There is inconsistent to no evidence to recommend the use of fish oils, evening primrose oil, borage
oil, multivitamin supplements, zinc, vitamin D, vitamin E, and vitamins B12 and B6 for the treatment of
AD.
12. Dietary controls

13. Factors that we should consider in dietary control
1. Food allergies may coexist and represent important triggers in a small subset of
individuals with AD, he true frequency of food allergies causing an isolated flare of disease is
probably low.
2. Elimination diets should not be initiated based on presence of AD or a suspicious history
alone, If allergy is suspected as a trigger of AD, a food diary recording symptoms and intake
can be helpful in identifying a specific food, a diagnostic elimination diet for up to 4 to 6
weeks with the suspected food item(s) may be initiated. If the individual’s AD remains stable
or even increases in severity, it is unlikely that the food is a relevant AD trigger and additional
testing is not necessary.
3. Multiple dietary restrictions and long-term dietary avoidance should only be undertaken
with documented, clinically relevant food allergies, Excessively restrictive diets, especially in
atopic children, have led to weight loss, poor growth, calcium deficiency, hypovitaminosis,
and kwashiorkor, Proper medical supervision, nutritional counseling from a dietician, and
supplementation should be included if elimination/avoidance diets are pursued for any
prolonged period of time.
4. The use of probiotics/prebiotics for the treatment of patients with established AD is not
recommended because of inconsistent evidence

14. 13. Environmental Modifications
There are less or no evidence to support to these modifications can improve
the condition of the patient with AD.
And finally the treatment for Ad should be individualized, we should consider
patient’s age, clinical symptoms, degree of the activity and the severity of the
disease. Therapeutic measures should be aimed at eliminating the
inflammatory process and as well as the extension of the state of the clinical
reference and the relapse prevention.
References
Eichenfield LF, Tom WL, Berger TG, Krol A, Paller AS, Schwarzenberger K, et al. Guidelines of care for the
management of atopic dermatitis: section 2. Management and treatment of atopic dermatitis with topical
therapies. J Am Acad Dermatol. 2014 Jul;71(1):116-32.
V.I.Stepanenko , Dermatology and Venerology
ABC of Dermatology

15. THANK YOU