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Atopic dermatitis

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Updated 2024 AAD guidelines for the management of atopic dermatitis.

Background

Overview

Definition
Atopic dermatitis, also known as atopic eczema, is a chronic relapsing inflammatory skin condition characterized by intense itching.
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Pathophysiology
Atopic dermatitis is caused by a complex interaction between defects in skin barrier function (caused by mutations in filaggrin gene), immune dysregulation, and environmental and infectious agents (S. aureus).
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Disease course
Skin barrier dysfunction and immune dysfunction results in atopic dermatitis, which causes clinical phases of acute atopic dermatitis (vesicular, weeping, crusting eruption), subacute atopic dermatitis (dry, scaly, erythematous papules and plaques), and chronic atopic dermatitis (lichenification, thickening, from repeated scratching). Atopic dermatitis precedes the development of food allergies, asthma, and allergic rhinitis. The disease decreases productivity and QoL.
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Prognosis and risk of recurrence
Atopic dermatitis is not associated with an increase in mortality.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of atopic dermatitis are prepared by our editorial team based on guidelines from the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2024), the American Academy of Dermatology (AAD 2024,2023,2014), the Harmonising Outcome Measures for Eczema (HOME 2024), the European Dermatology Forum (EDF 2022), the European Academy of Allergy and Clinical...
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Classification and risk stratification

Severity assessment: as per HOME 2024 guidelines, Use the following tools for the assessment of atopic dermatitis due to demonstrated sufficient content validity
EASI or modified EASI
SCORAD or objective SCORAD
SGA×BSA.
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Diagnostic investigations

Clinical history
As per AAD 2014 guidelines:
Assess for environmental and food allergies as part of the initial evaluation of patients with atopic dermatitis.
B
Assess for symptoms of itch, sleep disturbance, impact on daily activity, persistence of disease, and use currently available disease severity scales when practical.
B

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  • Biomarkers

  • Allergy testing

  • Specialized tests

  • Screening for associated conditions

Medical management

General principles: as per AAAAI/ACAAI 2024 guidelines, Verify the diagnosis before initiating any treatment in patients with atopic dermatitis of any severity. Ensure proper medication use/adherence.
E

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  • Topical corticosteroids

  • Topical calcineurin inhibitors

  • Topical PDE4 inhibitors

  • Topical JAK inhibitors

  • Topical antihistamines

  • Topical antimicrobials

  • Antiseptics

  • Systemic immunomodulatory agents

  • Systemic biologic agents

  • Systemic JAK inhibitors

  • Systemic corticosteroids

  • Systemic antibiotics

  • Antifungal therapy

  • Antiviral therapy

  • Systemic antihistamines

  • Management of pruritus

  • Allergen immunotherapy

  • Other agents

Nonpharmacologic interventions

Moisturizers and emollients
As per AAAAI/ACAAI 2024 guidelines:
Advise using a bland moisturizer titrated to symptomatic benefit (at least once, often multiple times, per day) in patients with atopic dermatitis.
E
Consider offering a standard, bland (free of fragrance and other potential contact allergens) OTC moisturizer over a prescription moisturizer medical device in patients with atopic dermatitis.
C

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  • Wet-wrap therapy

  • Bathing

  • Clothing and laundering

  • Allergen avoidance

  • Food elimination diets

  • Dietary supplements

  • Probiotics

  • Psychosocial interventions

  • Alternative and complementary therapies

Therapeutic procedures

Phototherapy: as per AAAAI/ACAAI 2024 guidelines, Consider offering clinic-based narrowband UVB phototherapy in patients with moderate-to-severe atopic dermatitis refractory, intolerant, or unable to use mid-to-high-potency topical treatment and systemic treatment, including biologic therapy.
C

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  • Immunoadsorption

Patient education

General counseling
As per EDF 2022 guidelines:
Educate patients/caregivers in lay language about treating and managing their own condition.
A
Provide patients/caregivers adequate knowledge, skills, resources, and support for the treatment of atopic dermatitis at home and coping with its impact on life.
A

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  • Occupational counseling

  • Educational programs

Preventative measures

Primary prevention: as per EAACI/EADV/EDF/EFA/ESDaP/ESPD/ETFAD/GA²LEN/UEMS 2018 guidelines, Advise exclusive breast milk feeding until 4 months of age for primary prevention of food allergy-associated atopic dermatitis.
B
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  • Routine immunizations