Domains Management advices
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.