Guideline for management of atopic dermatitis focuses on prevention of flares, long-term disease management

According to current estimates, up to 20 percent of children and 2 to 3 percent of adults have atopic dermatitis. This condition is associated with severe itching and an increased susceptibility to skin infections. Atopic dermatitis can have a major impact on the quality of life of patients and their family members. Studies show that the onset of atopic dermatitis is most common between three and six months of age.

"Whether you are a parent of a baby with atopic dermatitis or an adult with the condition, your dermatologist can help you develop a treatment plan that provides effective relief for this dry and itchy skin condition, maintain that relief, and prevent flare ups or complications," said board-certified dermatologist Brett M. Coldiron, MD, FAAD, president of the Academy. "This new guideline discusses proactive treatment that can help patients reduce disease severity and maintain treatment success for overall improved quality of life."

Atopic dermatitis management can benefit from a proactive approach To prevent flares, manage any other conditions associated with the disease and minimize complications, a proactive approach is now recommended for long-term disease management. Previous approaches to atopic dermatitis management were solely reactive. • Proactive management includes the intermittent, but scheduled use of topical corticosteroids or topical calcineurin inhibitors to areas of the body that frequently have recurrent disease. • Reactive management is to use these anti-inflammatory therapies only when new symptoms arise. • Regardless of which approach is used, moisturizers remain integral to prevent flare-ups.

"While both proactive and reactive approaches are still effective, patients may find greater success in controlling their flares or extending the period of time between flares, if they choose a proactive approach," said board-certified dermatologist, Lawrence F. Eichenfield, MD, FAAD, one of the authors of the Academy's newest guideline of care.

In addition to proactive disease management, the guidelines acknowledge the importance of patient and caregiver education. This education can include individualized "eczema schools," nurse-led programs or video-assisted approaches. These personalized or group education settings have been shown to increase patients' knowledge of the disease, improve their understanding of treatments and increase treatment compliance, which can reduce disease severity.

Establishing a link between allergens and atopic dermatitis remains challenging Patients and parents of young atopic dermatitis patient's often request allergy testing to find triggers that they hope will offer a "cure" or reduce the need for atopic dermatitis treatment.

"While atopic dermatitis patients have an increased rate of environmental and food allergies, there is typically not one allergy that is causing the disease," said Dr. Eichenfield. "It is very difficult to establish a connection between allergens and the initial atopic dermatitis diagnosis or to disease flare ups."

• Food allergies

o The impact of food exposure to atopic dermatitis remains unclear.

o  Positive allergy test results may reflect sensitization but often cannot be connected to atopic dermatitis.

o It is important to establish the presence of a true food allergy and to determine if the allergy is exacerbating the atopic dermatitis or if it is simply a co-existing condition with no impact on atopic dermatitis symptoms.

o The Academy's guidelines mirror those of the National Institute of Allergy and Infectious Disease.

o Food allergy evaluation is recommended for children under five-years-old with persistent moderate to severe atopic dermatitis despite effective treatment or who have a history of reaction after eating certain foods. This evaluation should be for the major food allergens, such as milk, egg, wheat, peanut and soy.

o Controlled food challenges remain the gold standard in verifying a positive skin or blood test for food allergy.

• Food elimination diets for the management of atopic dermatitis based solely on the presence of atopic disease, a suspected allergy or a positive skin or blood test are not recommended.

• Allergic contact dermatitis (ACD)

o Atopic dermatitis patients can have a high prevalence of ACD, a hypersensitivity reaction to certain substances that come in direct contact with the skin.

o Common contact allergens include nickel, neomycin (an antibiotic in wound care creams), fragrance, formaldehyde and other preservatives, lanolin and rubber chemicals.

o Patch testing should be done to positively diagnose ACD, as it can be difficult to visually distinguish from atopic dermatitis.

o Patch testing is an option for patients with persistent atopic dermatitis that is unresponsive to standard therapies, have affected areas unusual for atopic dermatitis, or those with clinical findings suggestive of ACD.

Use of alternative and complementary approaches for atopic dermatitis not proven The previous sections of the guideline series specify many medical treatments that are recommended for patients with atopic dermatitis. This guideline also reviews many of the complementary and alternative approaches patients often ask their dermatologist about.

Robert Sidbury, MD, FAAD, board-certified dermatologist and another lead author of the guidelines stated, "While there are many anecdotal tips and alternative options available to patients with atopic dermatitis, there is not enough evidence-based research to say for certain that these can provide any or better relief for patients, or be a complement to medical treatment."

For example, using specific laundering techniques or putting covers over pillows and mattresses to reduce dust mites, have not been shown to consistently improve atopic dermatitis. In addition, there has not been any evidence to show that following a specific diet or taking dietary supplements reduces or improves disease severity. Eastern medicine, such as Chinese herbal therapies, has been studied, but there are conflicting study results and concerns about liver toxicity with some of these herbal treatments. Other approaches that are lacking adequate evidence to make recommendations include massage therapy, aromatherapy, homeopathy and naturopathy.

"All four parts of these guidelines work together to offer guidance and provide the latest research to assist dermatologists and their patients in developing an effective treatment plan that addresses the long-term management of atopic dermatitis and improves the patient's quality of life," said Dr. Eichenfield.

The Academy's guidelines of care for the management of atopic dermatitis, parts 1, 2, 3 and 4 can be accessed here: http://www.aad.org/education/clinical-guidelines