New atopic dermatitis guidelines reviewed in workshop

Kelly M. Cordoro, MD: 'If we don't get to the matter of what matters to patients, we are not treating this disease at all.'

Kelly M. Cordoro, MD: ‘If we don’t get to the matter of what matters to patients, we are not treating this disease at all.’

The Academy’s atopic dermatitis (AD) guidelines were published last year, giving the dermatology community sufficient time to dissect the finer points of the recommendations, but dermatologists were reminded during an Annual Meeting session March 22 to never lose site of patient quality of life while examining the latest treatment options.

“If we don’t get to the matter of what matters to patients, we are not treating this disease at all,” said Kelly M. Cordoro, MD, associate professor of dermatology and pediatrics at the University of California, San Francisco. “And no matter what we talk about in terms of optimizing therapy, that only makes us feel good if our patients feel good as well. So, it is really important to address quality of life.”

Dr. Cordoro was one of four speakers who reviewed various aspects of the guidelines and compared them to European and Japanese guidelines, as well as allergy guidelines during a March 22 session, “Translating Evidence into Practice: Atopic Dermatitis Guidelines.”

Focusing on the Academy’s AD guidelines for the diagnosis and treatment of pediatric patients, Dr. Cordoro reminded dermatologists of some basics to keep in mind when facing a difficult diagnosis — the age of onset for atopic dermatitis is about three months, and there is no reliable biomarker to distinguish it from other conditions.

Another important factor is family history. If one parent has atopic dermatitis, a child has a twofold risk of having the condition. If both parents have AD, that risk increases fivefold, she said.

Also, age-specific patterns of AD are established. Infants have AD on the face, neck, and extensor areas, but not in the groin area. Older children have AD on the face, flexures, scalp, hands, and feet.

New data show that the introduction of solid foods, withholding allergenic foods, and maternal dietary modification do not appear to alter the risk for AD, Dr. Cordoro said. However, new data suggest that hydrolyzed formula and probiotic supplementation could have a beneficial effect in preventing AD in some high-risk infants who are not exclusively breast-fed.

AD patients often are sensitized to dust mite antigens, but there is no strong evidence that avoiding dust mites prevents atopic dermatitis, she said. In a related area, there is only mixed data about the effect of household pets on AD.

The Academy’s AD guidelines call wet wrap therapy a cornerstone of crisis control for pediatric patients. “The mechanism of action is to restore hydration,” Dr. Cordoro said. “It really is a wonderful way to get acute AD patients under control.”

If optimized topical regimens do not help control AD, “first-line” systemic treatment options should include narrowband ultraviolet B therapy or drugs, such as cyclosporine, methotrexate, or azathioprine, she said.

Peter A. Lio, MD, compared the approaches of dermatologists with allergists for diagnosing and treating AD. An assistant professor of clinical dermatology and pediatrics at Northwestern University Feinberg School of Medicine, he is in the unique position of being a member of a Joint Task Force Atopic Dermatitis Workgroup developed by the American College of Asthma, Allergy and Immunology and the American Academy of Asthma, Allergy and Immunology.

“We need to work as a team,” Dr. Lio said, adding that is to the ultimate benefit of patients. “The allergy focus is more on allergic triggers. They are more likely to use diet changes in treatment.”

The ACAAI/AAAAI Joint Task Force AD practice parameters were updated in 2012, and are “very much the same,” he said. “We agree on the basics,” referring to how the joint task force parameters compare to the AAD guidelines.

Those basics include: the use of moisturizers; stating there is a lack of evidence on emollients/barrier creams; maintenance therapy to prevent flares; use of wet wraps or dressings during disease flares; and no role for topical antihistamines.

But there are differences. The allergy guidelines do not discuss topical steroids or inhibitors as the AAD guidelines do. Regarding the use of systemic agents, data were reviewed, but no specifics were stated, Dr. Lio said.

One interesting difference is in the role of vitamin D. AAD guidelines say there is not enough evidence to support a position, while the allergy guidelines support its use, he said.

“Vitamin D might improve barrier function, reduce inflammation, and boost cathelicidin, and thus antimicrobial immunity,” Dr. Lio said, adding that there may be subgroups of AD patients who could benefit from the use of vitamin D.

Other differences are in environmental modification and the use of silver or silk clothing, which the allergy guidelines support, while the AAD guidelines say there is not evidence. In the area of food allergy testing, AAD guidelines support an elimination diet or an oral food challenge, while the allergy guidelines call for IgE testing and an oral food challenge only if IgE testing is negative.

Jon M. Hanifin, MD, the session director and professor of dermatology at Oregon Health & Science University, Portland, compared AAD and European guidelines. “There are few differences,” he said, adding that the European guidelines place more emphasis on IgE/Th2 features.

Nortio Katoh, MD, PhD, of the department of dermatology at Kyoto (Japan) Prefectural University of Medicine, compared the AAD guidelines with the two Japanese AD guidelines. The Japanese Dermatological Association has guidelines for dermatologists, while the Japanese Society of Allergology has guidelines for non-dermatologist physicians. The two Japanese guidelines are similar and share the same sources of evidence.

The take-home message from the Japanese guidelines, he said, is, “In our guidelines, we recommend to decide the potency of TCS (topical steroids) according to the severity of each eruption.

“Although oral antihistamines on pruritus in patients with AD are so far not recommended, their effect should be studied in more detail in many patients. Serum TARC may be a valuable biomarker reflecting disease severity and activity of AD.”

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