Discussion
A total of nineteen guidelines for the management of AD in children were
included in the study, thirteen of which were CPG and two guidelines
were in Chinese. The quality of the included guidelines was evaluated by
the AGREE II instrument,
and
three guidelines were rated A level and eleven were rated B level, which
was of high overall quality. Those who received a C-level quality rating
were mainly evidence-based expert consensus.
More research has been focused on AD worldwide with the development and
advancement of medicine, but it seems that the main treatment of AD has
not changed so much. AD occurs predominantly in infancy and early
childhood, symptoms are predominantly mild, with a few cases extending
into adulthood.41,42 All guidelines suggest that for
mild, non-episodic AD without other infections, the primary concern is
basic skin care, such as keeping skin moist and clean. Skin
moisturization and cleansing can reduce the severity of AD and the
frequency of medication use.43 The choice of
moisturizer can be based on patient preferences. There is no consensus
on the dosage, frequency and timing of application, but most guidelines
recommend choosing the dosage based on fingertip units (FTU), and
European guideline suggests specific dosages (shown in Table 5). Also,
it is recommended to use it together with medication to reduce the side
effects when it comes to flares. Skin cleansing is as important as
moisturizing. The use of a moisturizer immediately after the end of
daily bathing was agreed upon for this recommendation across guidelines.
There is no agreement on the time and temperature of bathing water, most
recommend 5 to 10 min and a water temperature of 27℃ to 40℃, water
temperature too high can cause itching of the skin.44Cleaners refer to patient preferences and try to use neutral or low pH,
non-allergenic substances or additives.
This study included AD guidelines published after 2016, and it can be
seen that the initial reports on the use of biologics were small sample
size studies, and their safety and efficacy could not be confirmed
especially in children, who are at high risk of AD and are more cautious
about the use of biologics. Dupilumab is the first biologic agent for
adult AD approved in Europe and FDA in 2017.45,46Dupilumab is a fully human monoclonal antibody that blocks the common
a-chain of the receptor for interleukin-4 and interleukin-13 that shows
positive control of the extent of AD lesions and pruritus symptoms.
Dupilumab was approved in South Korea in 2018 and China in 2020 for use
in adults with moderate to severe AD, respectively. With increased
relevant evidence, Dupilumab was approved by FDA in 2019 for adolescent
patients aged 12~17 years and in 2020 for pediatrics
aged 6~11 years with moderate-to-severe AD. Other
biologics such as omalizumab, Ustekinumab, rituximab, mepolizumab,
Nemolizumab, and alefacept are not recommended in the guidelines for now
due to the limited evidence available. Cost-effectiveness also needs to
be considered when using biologics for AD in
children.47
Traditional medicine such as Chinese herbal medicine, acupuncture,
massage, homeopathy, and aromatherapy, are widely used in some Asian
countries. However, the safety and efficiency of traditional medicine
are still waiting to be verified. For example, the use of herbal
medicine may cause metal element poisoning and increase the
nephrotoxicity of patients.48 Therefore, most existing
guidelines do not recommend conventional medicine for the treatment of
AD, and more research evidence is needed for its application in
children. It is noteworthy that 67.4% of AD patients in a survey
conducted in Hiroshima, Japan, used herbal medicine. In a questionnaire
survey of guardians of children with AD at their first visit in Tokyo,
patients with steroid phobia used traditional medicine more frequently
than patients without steroid phobia (22.2% vs. 13.0%,
P=0.013).27,49 China has published guidelines for
Chinese medicine to AD which to guide clinical practitioners in the
application of Chinese herbal medicines in 2021, which is currently only
available in Chinese and mentions limited evidence of effectiveness, and
more clinical studies are needed to confirm the efficacy of these herbal
medicines in the future.
In addition to traditional medicine, there are several complementary
treatments like dietary restrictions, essential fatty acids, vitamin D,
probiotics and allergen immunotherapy, etc. Above all, dietary
restrictions are not recommended especially for children, pregnant and
lactating women. Unless patients have a clear allergy to food or a
positive oral irritation test. Dietary restrictions can cause
malnutrition, which is difficult to implement in real life and reduces
the quality of life. Patients and family members must be informed of the
pros and cons of this method before implementation. Secondly, certain
agents such as essential fatty acids, vitamin D, and probiotics are not
recommended due to insufficient evidence available. In particular,
probiotics have been shown to have no significant effects in pediatrics
patients with AD. For allergen immunotherapy, it can be considered in
moderate to severe AD with a combination of allergic rhinitis, asthma,
dust mite, and pollen allergy, otherwise it is not recommended. However,
these conclusions may also be overturned later.
Almost all guidelines have mentioned patient education. Patient
education has been proven to reduce disease severity, improve quality of
life and improve mental health. Although patient education has never
been neglected, it still seems to be ineffective and steroid phobia has
not diminished over time. Patient education is an ongoing,
time-consuming, and high-volume effort that requires multidisciplinary
staff collaboration and includes pediatricians, dermatologists,
pharmacists, nursing staff, community workers, etc. There are different
forms of patient education in different national backgrounds.
Specialized outpatient clinics, brochures, inpatient lectures, online
videos and dedicated websites are the main modes of patient education.
Some developed countries from Europe carried out eczema action plans and
eczema schools, which may benefit from national policy support. The
implementation of patient education should take into account the
applicability and cost-effectiveness of the region where it is carried
out. The target of education is not only patients, but also family
members, especially parents of children, to increase patient compliance
and ensure the quality of life. Also, it is important to know that
patients and families learn to use some self-assessment tools such as
POEM so that they can be informed of the degree of control timely. In
the future, there is still a need to explore more methods of education
that can be satisfied by patients, families and staff to improve
compliance with AD treatment.