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• W76367842 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. 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. DisclaimerAdherence to these guidelines will not ensure successful treatment in every situation. Furthermore, these guidelines should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient, and the known variability and biologic behavior of the disease. This guideline reflects the best available data at the time the guideline was prepared. The results of future studies may require revisions to the recommendations in this guideline to reflect new data.ScopeThis guideline addresses the treatment of pediatric and adult atopic dermatitis (AD; atopic eczema) of all severities. The treatment of other forms of eczematous dermatitis is outside the scope of this document. Recommendations on AD management are subdivided into 4 sections given the significant breadth of the topic, and to update and expand on the clinical information and recommendations previously published in 2004. This document is the final in the series of 4 publications and discusses the management and control of AD flares using topical modalities and the utility and timing of allergen testing and avoidance. Also discussed is the use of adjunctive therapies and approaches, such as environmental, dietary, and educational interventions, in addition to complementary therapies.MethodA work group of recognized AD experts was convened to determine the audience and scope of the guideline and to identify important clinical questions in the management of flare progression and the use of adjunctive therapies and approaches (Table I). Work group members completed a disclosure of interests that was updated and reviewed for potential relevant conflicts of interest throughout guideline development. If a potential conflict was noted, the work group member recused him or herself from discussion and drafting of recommendations pertinent to the topic area of the disclosed interest.Table IClinical questions used to structure the evidence review for the management and treatment of atopic dermatitis with topical therapies• What are the most effective approaches to preventing flares in patients with atopic dermatitis?• What types of educational interventions are used in patients with atopic dermatitis to improve patient outcome, and are they effective?• What is the utility of screening for allergens on the course of atopic dermatitis and what are the suggested testing methods?• What is the effectiveness of dietary interventions, such as dietary restriction based on food allergy and sensitization testing, and the use of supplements, such as evening primrose oil, borage oil, fish oil, pyridoxine, vitamin E, multivitamins, and zinc for the treatment of atopic dermatitis?• What environmental modifications, such as house dust mite reduction, choice of clothing, irritant avoidance, and use of detergents can be implemented to influence the course of atopic dermatitis?• What is the effect of allergen-based interventions (eg, desensitization injections, allergen–antibody complexes of house dust mites) on the course of atopic dermatitis?• What is the effectiveness of complementary therapies, such as Chinese herbs and other supplements, homeopathy, and massage therapy for the treatment of atopic dermatitis? Open table in a new tab An evidence-based model was used, and evidence was obtained using a search of the PubMed and the Global Resources for Eczema Trials1Nankervis H. Maplethorpe A. Williams H.C. Mapping randomized controlled trials of treatments for eczema—the GREAT database (the Global Resource of EczemA Trials: a collection of key data on randomized controlled trials of treatments for eczema from 2000 to 2010).BMC Dermatol. 2011; 11: 10Crossref PubMed Scopus (11) Google Scholar databases from November 2003 through November 2012 for clinical questions addressed in the previous version of this guideline published in 2004, and from 1960 to 2012 for all newly identified clinical questions determined by the work group to be of importance to clinical care. Searches were prospectively limited to publications in the English language. Medical Subject Headings terms used in various combinations in the literature search included: atopic dermatitis, atopic eczema, surveillance, long-term management, short-term management, short-term care, long-term care, flare progression, relapse, patient follow-up, patient compliance, contact allergen, contact allergy screen, contact allergy test, desensitization, allergen antibody, antiallergen, antibody, dust mites, environmental, food allergy, irritant avoidance, detergent, clothing, diet, supplement, food introduction, oil, pyridoxine, vitamin, zinc, education, complementary, alternative, herb, supplement, homeopathy, massage, acupuncture, and Chinese medicine.A total of 2062 abstracts were initially assessed for possible inclusion. After the removal of duplicate data, 287 were retained for final review based on relevancy and the highest level of available evidence for the outlined clinical questions. Evidence tables were generated for these studies and used by the work group in developing recommendations. The Academy's previously published guidelines on AD were evaluated, as were other current published guidelines on AD.2Hanifin J.M. Cooper K.D. Ho V.C. Kang S. Krafchik B.R. Margolis D.J. et al.Guidelines of care for atopic dermatitis, developed in accordance with the American Academy of Dermatology (AAD)/American Academy of Dermatology Association “Administrative Regulations for Evidence-Based Clinical Practice Guidelines”.J Am Acad Dermatol. 2004; 50: 391-404Abstract Full Text Full Text PDF PubMed Scopus (228) Google Scholar, 3Ring J. Alomar A. Bieber T. Deleuran M. Fink-Wagner A. Gelmetti C. et al.Guidelines for treatment of atopic eczema (atopic dermatitis) part I.J Eur Acad Dermatol Venereol. 2012; 26: 1045-1060Crossref PubMed Scopus (24) Google Scholar, 4Ring J. Alomar A. Bieber T. Deleuran M. Fink-Wagner A. Gelmetti C. et al.Guidelines for treatment of atopic eczema (atopic dermatitis) Part II.J Eur Acad Dermatol Venereol. 2012; 26: 1176-1193Crossref PubMed Scopus (115) Google Scholar, 5Schneider L. Tilles S. Lio P. Boguniewicz M. Beck L. LeBovidge J. et al.Atopic dermatitis: a practice parameter update 2012.J Allergy Clin Immunol. 2013; 131 (e1-27): 295-299Abstract Full Text Full Text PDF PubMed Scopus (66) Google ScholarThe available evidence was evaluated using a unified system called the Strength of Recommendation Taxonomy (SORT) developed by editors of the US family medicine and primary care journals (ie, American Family Physician, Family Medicine, Journal of Family Practice, and BMJ USA).6Ebell M.H. Siwek J. Weiss B.D. Woolf S.H. Susman J. Ewigman B. et al.Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature.J Am Board Fam Pract. 2004; 17: 59-67Crossref PubMed Google Scholar Evidence was graded using a 3-point scale based on the quality of methodology (eg, randomized control trial, case control, prospective/retrospective cohort, case series, etc) and the overall focus of the study (ie, diagnosis, treatment/prevention/screening, or prognosis) as follows:I.Good-quality patient-oriented evidence (ie, evidence measuring outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life).II.Limited-quality patient-oriented evidence.III.Other evidence, including consensus guidelines, opinion, case studies, or disease-oriented evidence (ie, evidence measuring intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes).Clinical recommendations were developed based on the best available evidence tabled in the guideline. These are ranked as follows:A.Recommendation based on consistent and good-quality patient-oriented evidence.B.Recommendation based on inconsistent or limited-quality patient-oriented evidence.C.Recommendation based on consensus, opinion, case studies, or disease-oriented evidence.In those situations where documented evidence-based data are not available, we have used expert opinion to generate our clinical recommendations.This guideline has been developed in accordance with the American Academy of Dermatology (AAD)/AAD Association Administrative Regulations for Evidence-based Clinical Practice Guidelines (version approved May 2010), which includes the opportunity for review and comment by the entire AAD membership and final review and approval by the AAD Board of Directors.7American Academy of Dermatology web site. Administrative regulations. Evidence-based clinical practice guidelines. Available at: www.aad.org/Forms/Policies/Uploads/AR/AR%20-%20Evidence-Based%20Clinical%20Guideline.pdf. Accessed November 12, 2011.Google Scholar This guideline will be considered current for a period of 5 years from the date of publication, unless reaffirmed, updated, or retired at or before that time.DefinitionAD 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.IntroductionThe often protracted nature of AD necessitates setting several long-term treatment goals: the prevention of continued outbreaks, the management of comorbidities and secondary complications that arise, and minimizing adverse effects while trying to maximize positive outcomes. Clinical studies focused on more extended disease control have increased in recent years. Additional data regarding allergic comorbidities support the need for testing or intervention, but only in particular instances. In addition to the topical and systemic approaches reviewed in earlier parts of these guidelines, multiple adjunctive and complementary modalities have been tried, with varying degrees of success. Discussion of these measures and suggestions on their use are provided based on the available evidence.Prevention of disease flaresAD is characterized by periods of acute worsening (“flares”) alternating with periods of relative quiescence after treatment. The precise definition of a flare, however, differs across studies and is an ongoing area of research.8Langan S.M. Schmitt J. Williams H.C. Smith S. Thomas K.S. How are eczema “flares” defined? A systematic review and recommendation for future studies.Br J Dermatol. 2014; 170: 548-556Crossref PubMed Google Scholar For pragmatic reasons, the definitions of flare from each published paper have been accepted for this guideline.The strategy required to minimize recurrence varies depending on the individual and his or her frequency, severity, and sites of disease. Moisturizers should be an integral part of the maintenance treatment plan given their low risk and ability to improve skin hydration; some may also address the negative effects of epidermal barrier dysfunction.9Loden M. Andersson A.C. Lindberg M. Improvement in skin barrier function in patients with atopic dermatitis after treatment with a moisturizing cream (Canoderm).Br J Dermatol. 1999; 140: 264-267Crossref PubMed Scopus (152) Google Scholar, 10Breternitz M. Kowatzki D. Langenauer M. Elsner P. Fluhr J.W. Placebo-controlled, double-blind, randomized, prospective study of a glycerol-based emollient on eczematous skin in atopic dermatitis: biophysical and clinical evaluation.Skin Pharmacol Physiol. 2008; 21: 39-45Crossref PubMed Scopus (41) Google Scholar, 11Chamlin S.L. Kao J. Frieden I.J. Sheu M.Y. Fowler A.J. Fluhr J.W. et al.Ceramide-dominant barrier repair lipids alleviate childhood atopic dermatitis: changes in barrier function provide a sensitive indicator of disease activity.J Am Acad Dermatol. 2002; 47: 198-208Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar Two studies have shown that daily moisturizer use can lengthen the time to first flare, compared to no treatment.12Szczepanowska J. Reich A. Szepietowski J.C. Emollients improve treatment results with topical corticosteroids in childhood atopic dermatitis: a randomized comparative study.Pediatr Allergy Immunol. 2008; 19: 614-618Crossref PubMed Scopus (47) Google Scholar, 13Wiren K. Nohlgard C. Nyberg F. Holm L. Svensson M. Johannesson A. et al.Treatment with a barrier-strengthening moisturizing cream delays relapse of atopic dermatitis: a prospective and randomized controlled clinical trial.J Eur Acad Dermatol Venereol. 2009; 23: 1267-1272Crossref PubMed Scopus (45) Google Scholar In some cases, this strategy may be adequate and antiinflammatory therapies reinstituted only when new eczematous lesions are noted.13Wiren K. Nohlgard C. Nyberg F. Holm L. Svensson M. Johannesson A. et al.Treatment with a barrier-strengthening moisturizing cream delays relapse of atopic dermatitis: a prospective and randomized controlled clinical trial.J Eur Acad Dermatol Venereol. 2009; 23: 1267-1272Crossref PubMed Scopus (45) Google Scholar, 14Hanifin J. Gupta A.K. Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients.Br J Dermatol. 2002; 147: 528-537Crossref PubMed Scopus (122) Google Scholar, 15Siegfried E. Korman N. Molina C. Kianifard F. Abrams K. Safety and efficacy of early intervention with pimecrolimus cream 1% combined with corticosteroids for major flares in infants and children with atopic dermatitis.J Dermatolog Treat. 2006; 17: 143-150Crossref PubMed Scopus (22) Google Scholar This is considered a reactive approach to long-term management.However, some individuals benefit from a more proactive method, whereby topical corticosteroids (TCS) or topical calcineurin inhibitors (TCI) are applied to both previously and newly involved skin on a scheduled, intermittent basis and moisturizers used on all areas. Five randomized controlled trials (RCTs) with up to 4 weeks of acute disease control followed by twice weekly application of a midpotency TCS (fluticasone propionate or methylprednisolone aceponate) for 16 to 20 weeks demonstrated a reduction in the risk of flare development and lengthening of the time to relapse or first flare, relative to vehicle.14Hanifin J. Gupta A.K. Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients.Br J Dermatol. 2002; 147: 528-537Crossref PubMed Scopus (122) Google Scholar, 16Berth-Jones J. Damstra R.J. Golsch S. Livden J.K. Van Hooteghem O. Allegra F. et al.Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study.BMJ. 2003; 326: 1367Crossref PubMed Google Scholar, 17Glazenburg E.J. Wolkerstorfer A. Gerretsen A.L. Mulder P.G. Oranje A.P. Efficacy and safety of fluticasone propionate 0.005% ointment in the long-term maintenance treatment of children with atopic dermatitis: differences between boys and girls?.Pediatr Allergy Immunol. 2009; 20: 59-66Crossref PubMed Scopus (26) Google Scholar, 18Peserico A. Stadtler G. Sebastian M. Fernandez R.S. Vick K. Bieber T. Reduction of relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly in addition to maintenance treatment with emollient: a multicentre, randomized, double-blind, controlled study.Br J Dermatol. 2008; 158: 801-807Crossref PubMed Scopus (49) Google Scholar, 19Van Der Meer J.B. Glazenburg E.J. Mulder P.G. Eggink H.F. Coenraads P.J. The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group.Br J Dermatol. 1999; 140: 1114-1121Crossref PubMed Google Scholar A metaanalysis of the fluticasone studies found a substantial magnitude of benefit (pooled relative risk of flares of 0.46 [95% confidence interval {CI}, 0.38-0.55] vs vehicle).20Schmitt J. von Kobyletzki L. Svensson A. Apfelbacher C. Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials.Br J Dermatol. 2011; 164: 415-428Crossref PubMed Scopus (66) Google Scholar Two to 3 times weekly application of topical tacrolimus (0.03% in children, 0.1% in adults) to previously affected sites revealed similar benefits over 40 to 52 weeks of use (3 RCTs, pooled relative risk of flares of 0.78 [95% CI, 0.60-1.00]).20Schmitt J. von Kobyletzki L. Svensson A. Apfelbacher C. Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials.Br J Dermatol. 2011; 164: 415-428Crossref PubMed Scopus (66) Google Scholar, 21Breneman D. Fleischer Jr., A.B. Abramovits W. Zeichner J. Gold M.H. Kirsner R.S. et al.Intermittent therapy for flare prevention and long-term disease control in stabilized atopic dermatitis: a randomized comparison of 3-times-weekly applications of tacrolimus ointment versus vehicle.J Am Acad Dermatol. 2008; 58: 990-999Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 22Thaci D. Chambers C. Sidhu M. Dorsch B. Ehlken B. Fuchs S. Twice-weekly treatment with tacrolimus 0.03% ointment in children with atopic dermatitis: clinical efficacy and economic impact over 12 months.J Eur Acad Dermatol Venereol. 2010; 24: 1040-1046PubMed Google Scholar, 23Wollenberg A. Reitamo S. Girolomoni G. Lahfa M. Ruzicka T. Healy E. et al.Proactive treatment of atopic dermatitis in adults with 0.1% tacrolimus ointment.Allergy. 2008; 63: 742-750Crossref Scopus (119) Google Scholar This method of TCI use also led to a decrease in the number of flares and an increase in days free of topical antiinflammatory use compared to vehicle. The recommendation for flare prevention is in Table II and level of evidence in Table III. Further supporting proactive treatment are histologic findings of a persistently abnormal epidermal barrier and residual low-grade inflammation at previously involved sites, even when there is little clinical evidence of involvement.24Suarez-Farinas M. Tintle S.J. Shemer A. Chiricozzi A. Nograles K. Cardinale I. et al.Nonlesional atopic dermatitis skin is characterized by broad terminal differentiation defects and variable immune abnormalities.J Allergy Clin Immunol. 2011; 127 (e1-4): 954-964Abstract Full Text Full Text PDF PubMed Scopus (53) Google ScholarTable IIRecommendation for prevention of flares of atopic dermatitisContinued 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. Open table in a new tab Table IIIStrength of recommendations for the use of topical therapies for flare prevention and for adjunctive and complementary interventions for the treatment of atopic dermatitisTherapy/interventionStrength of recommendationLevel of evidenceReferencesProactive use of topical corticosteroidsAI14Hanifin J. Gupta A.K. Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients.Br J Dermatol. 2002; 147: 528-537Crossref PubMed Scopus (122) Google Scholar, 16Berth-Jones J. Damstra R.J. Golsch S. Livden J.K. Van Hooteghem O. Allegra F. et al.Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study.BMJ. 2003; 326: 1367Crossref PubMed Google Scholar, 17Glazenburg E.J. Wolkerstorfer A. Gerretsen A.L. Mulder P.G. Oranje A.P. Efficacy and safety of fluticasone propionate 0.005% ointment in the long-term maintenance treatment of children with atopic dermatitis: differences between boys and girls?.Pediatr Allergy Immunol. 2009; 20: 59-66Crossref PubMed Scopus (26) Google Scholar, 18Peserico A. Stadtler G. Sebastian M. Fernandez R.S. Vick K. Bieber T. Reduction of relapses of atopic dermatitis with methylprednisolone aceponate cream twice weekly in addition to maintenance treatment with emollient: a multicentre, randomized, double-blind, controlled study.Br J Dermatol. 2008; 158: 801-807Crossref PubMed Scopus (49) Google Scholar, 19Van Der Meer J.B. Glazenburg E.J. Mulder P.G. Eggink H.F. Coenraads P.J. The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic DermatitisStudy Group.Br J Dermatol. 1999; 140: 1114-1121Crossref PubMed Google Scholar, 20Schmitt J. von Kobyletzki L. Svensson A. Apfelbacher C. Efficacy and tolerability of proactive treatment with topical corticosteroids and calcineurin inhibitors for atopic eczema: systematic review and meta-analysis of randomized controlled trials.Br J Dermatol. 2011; 164: 415-428Crossref PubMed Scopus (66) Google ScholarProactive use of topical calcineurin inhibitorsAI21Breneman D. Fleischer Jr., A.B. Abramovits W. Zeichner J. Gold M.H. Kirsner R.S. et al.Intermittent therapy for flare prevention and long-term disease control in stabilized atopic dermatitis: a randomized comparison of 3-times-weekly applications of tacrolimus ointment versus vehicle.J Am Acad Dermatol. 2008; 58: 990-999Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 22Thaci D. Chambers C. Sidhu M. Dorsch B. Ehlken B. Fuchs S. Twice-weekly treatment with tacrolimus 0.03% ointment in children with atopic dermatitis: clinical efficacy and economic impact over 12 months.J Eur Acad Dermatol Venereol. 2010; 24: 1040-1046PubMed Google Scholar, 23Wollenberg A. 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• W76367842 title "Guidelines of care for the management of atopic dermatitis" @default.
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