Severity assessment |
Commonly
used assessment scales are Scoring of Atopic Dermatitis’ (SCORAD),
Eczema Area and Severity Score (EASI), Patient-Oriented Eczema Measures
for Eczema (POEM). Professionals can use the tool Investigators’ Global
Assessment (IGA). |
Moisturizing |
Emollient
is the most basic and important treatment strategy. There is already
lots of evidences that emollient and cleansing can reduce the severity
of disease and decrease medication use. There is no standard for
emollients use frequency. Most guidelines recommend using adequate
emollients at least twice a day, in conjunction with medication during
an attack. The choice of emollient can be based on patient preference
and physician recommendations. There is also no standard dosage for
emollients, and fingertip units are recommended, with a dosage range of
100~200 g/week for children and 250~500
g/week for adults from Europe guide. |
Cleansing |
It is recommended to bathe daily and use emollients
immediately after bathing. The recommended water temperature range is
27~40℃ and the duration is 5~10min.
Choose a neutral or low pH, preservative-free cleanser, check for
allergenic substances or fragrance, and choose according to season,
patient’s age, the site of application. Meanwhile choose with reference
to the patient’s preference. |
Bleaching
bath |
Guidelines have different opinions. Some guidelines suggesting
that a 0.005% bleaching bath with the addition of sodium hypochlorite
may reduce the use of topical anti-inflammatory medications and
antibiotics, inhibit bacterial activity. However, some guidelines have
reservations about whether bleaching baths can change the severity of
the disease. |
Wet-warp
therapy |
Wet-warp
therapy (WWT) consists of a double layer of gauze or tubular bandage,
with a wet inner layer and a dry outer layer. Commonly used in
moderate-to-severe AD, acute phase, exudate, corrosive lesions during
exacerbation. WWT can be used with emollient cream alone or in
combination with TCS. WWT has been shown to increase the absorb of TCS
and reduce disease severity and water loss during flares. WWT is also a
relatively safe and effective treatment for children, with an age
recommendation of over 6 months and a duration of use usually not
exceeding 14 days. Side effects of glucocorticoids after systemic
absorption need to be noted. |
Topical glucocorticoids
|
1. Principle: Adequate strength, dosage and reasonable application
2. Dosage: The average dose is 15g per month for infants, 30g per month
for children, and 60~90g per month for adolescents and
adults.
3. Frequency: For mild AD, 1~2 times per day during
flare-ups and 2~3 times per week for maintenance
treatment.
4. Selection factors: efficacy, formulation, patient age and site of
application, severity, patient preference, and costs.
5. Medication strength grade: Mostly divided into 4 levels (very strong,
strong, medium, weak), Japan is divided into 5 levels (strongest, very
strong, strong, medium, weak)
6. Special position: The facial area, especially the eyes, neck, scalp
of infants, skin folds, genitals need to be used with caution.
7. Length of use: No more than 6 months
8.
Side effect: Be alert to systemic or local side effects caused by
improper application, frequency of use, and
improper
duration of use
|
Topical Calcineurin Inhibitors
|
Most commonly used drugs are Tacrolimus and
Pimecrolimus.
Children are of special medication age.
1. Time to use: Generally, it is used in the acute period that is a TCS
replacement therapy. TCI can be used for special location like face and
genitals when TCS is not tolerated or side effects occur.
2. Age: 1% Pimecrolimus is for children over 2 years or older. 0.03%
Pimecrolimus for patients aged 2~15 years. 0.1%
tacrolimus is for adolescents over 16 years or older.
3. Frequency: 2~3times per week for active treatment.
4. Dosage: 0.03% Tacrolimus: 1g for children 2~5 years
(weight < 20 kg), 2~4g for
6~12 years (weight 20~50 kg) and max 5 g
for 13 years or older (weight ≥ 50 kg).
5. Pay attention to sunscreen when using TCI.
|
Topical Antibiotics |
Routine application is not recommended for
non-infectious AD. AD is often caused by Staphylococcus aureus when
accompanied by skin infections, so it is recommended to consider topical
antibiotic treatment in the presence of obvious signs of infection, but
long-term use of topical antibiotics is not recommended and may increase
the risk of drug resistance and sensitization. Commonly used drugs can
be seen as fusidic acid and mupirocin, and the duration of use is
recommended to last 7~10 days or no more than one week,
2~3 times per day. |
Phosphodiesterase Inhibitor |
Commonly used drugs include Crisaborole
and Apremilast which have increased evidences in recent years and have
been shown to reduce severity. Phosphodiesterase inhibitor are approved
in some countries for mild and moderate AD over two years of age.
Consider the cost when using. |
Glucocorticoids |
Short-term use in moderate to severe acute attacks is
recommended. Avoid side effects of long-term use. Use for a period of no
more than 1~2 weeks. More caution when used by children.
The Italian consensus does not recommend use in children, as rebound or
worsening of symptoms may occur after discontinuation of the
drug. |
Immunity
Inhibitor |
As second-line therapeutic agents, commonly used are
cyclosporin, azathioprine, mycophenolate mofetil, and methotrexate as
treatment options for refractory or severe AD, which are over-indicated
for both children and adolescents, with monitoring for adverse effects
during use. They may be teratogenic when used in pregnant women under
strict indications. The dose used varies from country to
country. |
Systematic
Antibiotics |
Systematic use of antibiotics is recommended when there
are obvious signs of infection. Cephalosporin is recommended as the
first choice, avoid long-term use and use for no longer than two
weeks. |
Antihistamine |
Initially most guidelines did not recommend
antihistamines because there was little evidence of their effectiveness
in controlling pruritic symptoms, and because sedating antihistamines
may affect sleep quality in children. As research evidence increased,
some guidelines considered as adjunctive therapy, combined with topical
anti-inflammatory agents to reduce pruritic symptoms, and recommended
the use of non-sedating antihistamines. Patients with sleep disorders
could be given sedating antihistamines for a short time. |
Biological Agents |
Evidence on the efficacy and safety of biologic
agents for the treatment of AD is gradually increasing, but still as a
complementary treatment to AD therapy or in refractory,
moderate-to-severe patients.
Dupilumab is the first biologic
agent for moderate-to-severe AD adults that approved by FDA and Europe
standards in 2017. Dupilumab was approved by FDA for use in children
over six years of age in 2020. It is recommended to use in combination
with topical emollients and anti-inflammatory drugs, and to consider the
cost effectiveness. Omalizumab, ustekinumab, rituximab, mepolizumab,
nemolizumab and alefacept are not recommended due to limited
evidence. |
Phototherapy |
Phototherapy is the second-line treatment for AD. Common
forms of phototherapy are UVA-1 therapy for acute flares and UVB
narrowband therapy for severe chronic maintenance treatment. Most
guidelines recommend the use of phototherapy beyond the age of
10~18 years and 2~3 times a week.
Selection of phototherapy modality based on feasibility, cost, patient
skin type, skin cancer history, and use of photosensitizing
drugs. |
Alternative Medicine |
Evidence is insufficient to recommend the use of
alternative medicine such as herbal medicine, acupuncture, massage,
aromatherapy, homeopathy, etc. Patients using
alternative
medicine should be informed of the potential hazards and should not
replace conventional treatment. |
Diet |
Diet
restriction is not recommended unless there is a clear history of
allergy or a positive oral irritation test. If it is necessary, it is
recommended that it be done under expert guidance to avoid dietary
errors or malnutrition, and only after informing family members of the
limited benefits and possible harms of elimination diets. Infants are
recommended to be breastfed until four months of age, and diversity is
observed when food is introduced between four and six months.
Supplementation is not recommended to administer AD. Diet restriction is
not recommended for pregnant and breastfeeding women to prevent
AD. |
Essential fatty acid |
Routine supplementation with essential fatty
acids is not recommended for the management of AD because of limited
evidence. However, some guidelines suggest that oral essential fatty
acid and topical application as a component of emollients is recommended
in some cases. |
Probiotics |
Although there are studies have confirmed that probiotics
can reduce AD severity compared to controls, there is no evidence to
support the benefits of probiotics in children. The routine use of
probiotics for AD management is not recommended. |
Vitamin D |
Limited evidence finds that vitamins may be useful for AD
management, but not enough to support that vitamin D supplementation can
be a treatment method. |
Allergen specific immunotherapy; |
ASIT is not recommended as a routine
treatment option and can be used for patients with combined allergic
rhinitis, bronchial asthma, dust mite, pollen allergy, or moderate to
severe exposure to allergens. |
Patient education |
Patient education is needed throughout the AD
management process. Reducing steroid phobia can effectively increase
compliance with medication and reduce relapse. Patient education needs a
professional multidisciplinary team to carry out and adopt a specific
educational model for different cultures. |
Fingertip unit |
When using emollients, TCS and TCI it is recommended to
use fingertip unit to prevent over or under dosage. FTU is the dose
squeezed from the tip to the first joint along the index finger in
adults (~0.5 g).
1
FTU is approximately equivalent to taking an appropriate amount of thin
and evenly applied to the skin area equivalent to 2 adult hands, the
dose required for children is age-related. |