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Atopic dermatitis

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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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 Dermatology (AAD 2024; 2023; 2014), the American Academy of Allergy, Asthma & Immunology (AAAAI/ACAAI 2023), the European Dermatology Forum (EDF 2022), the European Academy of Allergy and Clinical Immunology (EAACI 2021), the European Academy of Dermatology and Venereology (EADV/ETFAD 2020), the European Academy of Dermatology and Venereology (EADV/UEMS/EFA/GA²LEN/ETFAD/EDF/EAACI/ESDaP/ESPD 2018), and the European Academy of Dermatology and Venereology (EADV/UEMS/EFA/ETFAD/EDF/EAACI/ESDaP/ESPD 2018).
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Guidelines

1.Classification and risk stratification

Severity grading: do not use available disease severity or patient QoL measurement scales in routine clinical practice in the management of patients with atopic dermatitis.
D
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2.Diagnostic investigations

Clinical history
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

3.Medical management

General principles: as per AAAAI 2023 guidelines, verify the diagnosis before initiating any treatment in patients with atopic dermatitis of any severity. Ensure proper medication use/adherence.
B

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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

4.Nonpharmacologic interventions

Moisturizers and emollients
As per AAAAI 2023 guidelines:
Advise using a bland moisturizer titrated to symptomatic benefit (at least once, often multiple times, per day) in patients with atopic dermatitis.
B
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

5.Therapeutic procedures

Phototherapy
As per AAD 2024 guidelines:
Consider offering phototherapy in adult patients with atopic dermatitis.
C
Insufficient evidence to recommend PUVA phototherapy for the management of atopic dermatitis.
I

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6.Patient education

General counseling
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

7.Preventative measures

Primary prevention: 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