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Awaiting dx & tx decision
Dx based on hx, clinical signs, and skin lesion morphology. No reliable biomarkers for dx. Dz severity informs tx decisions. - Essential/hallmark features: pruritis/scratching, chronic or relapsing (or both) eczematous lesions;1,2 common lesion findings: erythema, edema, erosions/excoriations, oozing, lichenification.1,3
- Rash distribution changes w/ age: face, neck, and extensor surfaces common in infants and young kids;1,4 flexural lesions occur at any age, but localized, lichenified flexural lesions more common in older kids and adults;4 spares groin and axillae.1
- Classical features can vary among skin tones—e.g., erythema includes transient skin alternations characteristic of active AD inflammation including red, shades of brown, violaceous, or gray appearances. Postinflammatory dyspigmentation (hypo- or hyperpigmentation) may persist for months to years. However, AD care principles remain similar for all skin types. See https://eczemainskinofcolor.org/ and https://nationaleczema.org/eczema-skin-of-color/.2
- Features supporting dx: early age @ onset (≈60% by age 1y, ≈85%-90% by age 5y);1,2 PMHx or FHx of atopy; hx of IgE reactivity.1
- Other tests not routine: Skin bx, serum IgE, KOH prep, patch testing, and/or genetic testing may be helpful to r/o other/associated skin conditions.1
- Serum IgE: not reliable for definitive dx; total or allergen-specific serum IgE positive in most pts w/ AD2 (≈80%, per AAD),1 but allergen-specific levels also positive in ≈55% of gen population;1 levels vary w/ severity,1,2 but false positives limit utility, so don’t follow IgE;1 along w/ FLG gene null mutations, may be prognostic for severe/protracted dz.1
- Assess severity: Available dz severity and QOL scales not recommended for routine clinical use; ask about itch, sleep, impact on daily activity, and dz persistence instead.1
Footnotes 1 AAD1 2014. Eichenfield LF, et al. Guidelines of care for the management of atopic dermatitis: Part 1. Diagnosis and assessment of atopic dermatitis.
J Am Acad Dermatol. 2014 Feb;70(2):338-351. Free full-text PDF at PubMed Central®
2 AAAAI/ACAAI 2023. Chu DK, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2023 Dec 18:S1081-1206(23)01455-2. Free full-text PDF
3 ESC 2017. Wong ITY, et al. Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Can Pharm J (Ott). 2017 May 30;150(5):285-297. Free full-text PDF at PubMed Central®
4 AAAAI/ACAAI 2012. Schneider L, et al. Atopic dermatitis: a practice parameter update 2012. J Allergy Clin Immunol. 2013 Feb;131(2):295-9.e1-27. Free full-text PDF
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Initial tx mild/moderate active dz
Basic skin care plus topical anti-inflammatories improve sx and reduce flares. - Basic skin care: Use moisturizers1,2 (may be applied soon after bathing);2,3 when using a moisturizer, consider its allergenic potential, palatability, heterogeneity in formulations and trial data, paucity of data in pts w/ skin of color, and cost;1,2 avoid aggravating factors (e.g., long hot baths/showers; irritants such as soaps/cleansers, fragrances, wool, etc.);3 bathing is conditionally recommended for tx and maintenance in adults.2
- Use TCS in adults w/ AD2 if no response to basic skin care;1 consider pt’s body area2 and lesion severity3 when selecting TCS: typically, lower potency in areas of thin skin (face, neck, genitals, skin folds);1-3 qd application may be sufficient for potent TCS;2 qd application of TCS may be as effective as bid (although bid may be considered for more-severe flare or pts who want quick resolution or respond better to bid1);3 monitor PE for cutaneous AEs (esp. skin atrophy); risk factors for atrophy include higher-potency TCS use, occlusion, use on thinner and intertriginous skin, older pt age, and long-term continuous TCS use; minimize periocular steroid use (even though association w/ cataracts or glaucoma is unclear);2 see epocrates’ Topical Corticosteroid Potencies tool.
- TCIs a steroid-sparing alternative;1-3 consider using to avoid skin atrophy, telangiectasia, striae on face, skin folds when low-potency TCS not effective;1 use tacrolimus 0.03% or 0.1% oint in adults;2 use pimecrolimus 1% crm in adults w/ mild to moderate AD;2 consider w/ periocular AD, where TCS may also ↑ risk of cataracts/glaucoma;3 however, TCIs may initially burn/itch (tacrolimus may cause local irritation, at least initially)1-3 and have black box warning for rare cutaneous CA and lymphoma risk2 (though causal relationship not established;3 also, several long-term studies suggest ↑relative risk of lymphoma w/ TCI use, but given the low absolute risk, CA risk isn’t likely clinically meaningful2); pts receiving combo of tacrolimus 0.1% oint and clocortolone pivalate 0.1% crm bid achieved significantly better dermatologic sum scores (measure excoriation, induration, and erythema) than pts receiving mono-tx w/ either agent.2
- Photo-tx (moderate to severe dz only): 2nd-line after failure of basic skin care, TCS, and TCI;1,3,4 can be used concurrently w/ topical agents as maintenance or rescue tx or to treat flares.4
- Systemic agents indicated for moderate to severe dz when optimized topical tx and/or photo-tx don’t adequately control dz, or when dz severity substantially impacts QOL.1,3,4
- Strongly recommend: dupilumab, tralokinumab,1,4 abrocitinib, baricitinib, upadacitinib.4
- Conditionally recommend: cyclosporine modified,1,4 MTX, mycophenolate mofetil, azathioprine,4 abrocitinib, baricitinib, upadacitinib.1
- Conditionally recommend against: MTX, mycophenolate mofetil, azathioprine.1
- Insufficient data: systemic abx, PO antihistamines, montelukast, apremilast, ustekinumab, IVIG, interferon-γ, omalizumab, TNF-α inhibitors, systemic calcineurin inhibitors (other than cyclosporine), mepolizumab.4
- Avoid systemic steroids; consider only for acute, severe exacerbations or as short-term bridge tx to other systemic, steroid-sparing tx.4
- Consider sedating PO antihistamines for pruritis, esp. if sleep interrupted.3
- Anti-staph tx not routine: AAD conditionally recommends against topical antiseptics for AD, but bleach baths or topical NaOCl may be suggested to ↓ dz severity in pts w/ moderate to severe AD w/ clinical signs of secondary bacterial infxn;2 AAAAI suggests bleach baths as additive tx for moderate to severe but not mild dz;1 can consider dilute bleach baths 2x/wk and intranasal mupirocin to ↓ AD severity, per AAAAI (esp. in pts w/ recurrent skin infxn);1 systemic abx also appropriate w/ clinically evident infxn.4
- Topical PDE-4 inhibitors: Use crisaborole 2% oint in adults w/ mild to moderate AD (as an alternative to TCS and TCI).1,2
- Topical JAK inhibitors: FDA approved ruxolitinib 1.5% crm for short-term and noncontinuous chronic tx in pts ≥12 yo w/ mild to moderate AD (don’t exceed 20% of BSA or apply >60 g/wk); black box warnings include serious infxns, mortality, malignancies (e.g., lymphoma), MACE, and thrombosis.2 AAAAI/ACAAI suggests against adding topical JAK inhibitors for mild to moderate AD refractory to moisturization alone.1
- Oral JAK inhibitors: After considering risks and possible benefits, may use in adults and adolescents w/ moderate to severe AD refractory to or who can’t tolerate/use mid- to high-potency topical tx and systemic tx including a previously recommended biologic. AAAAI/ACAAI conditionally recommends replacing systemic tx w/ one of the following (in alpha order): abrocitinib 100-200 mg (≥12 yo); baricitinib 2-4 mg (not FDA approved for AD); upadacitinib 15-30 mg (≥12 yo). However, in most pts w/ mild to moderate AD, risk of oral JAK inhibitor may be higher than topical one. AAAAI/ACAAI conditionally recommends against azathioprine.1
- Wet wrap tx (typically w/ low- or mid-potency TCS) is an effective option to control AD flares and mitigate recalcitrant dz; wet dressings are conditionally recommended in adults w/ moderate to severe AD experiencing a flare; require ↑effort and time, as well as pt education, to ensure correctness.2
- Structured pt education recommended as adjunct to tx:1 nurse-5 or pharmacist-led3 programs, video interventions can be considered.5
- Elicit hx of environmental, food, or contact allergies.1,5 AAD says to pursue testing only w/ concerning hx—e.g., in kids <5 yo w/ moderate/severe dz and hx of immediate reaction, consider testing for milk, egg, peanut, wheat, and soy allergy;5 however, AAAAI/ACAAI recommends against allergy testing for food elimination, as food removal in a sensitized but unexposed infant could increase risk of developing IgE-mediated food allergy. Also, risk for malnutrition would favor against pursuing an elimination diet.1 Don’t base food elimination diets solely on test results.1,5
- SLIT/SCIT: AAAAI/ACAAI conditionally recommends as adjunct for pts w/ moderate to severe dz refractory to or who can’t tolerate/use midpotency topicals, and conditionally recommends against for mild dz; however, may benefit allergic comorbidities, even in mild AD, where net benefit is small.1
- Insufficient evidence: fish oils, evening primrose oil, borage oil, multivitamins, zinc, vit D, vit E, vit B12 and B6, special clothing fabrics, Chinese herbal meds, massage tx, aromatherapy, naturopathy, hypnotherapy, acupressure, or autologous blood injections.5
- Limited available evidence: use of a particular moisturizer or active ingredient in an emollient; a standard for the frequency or duration of bathing, temp of water, type of soap, and use of water softeners, and other bathing accessories, including bleach, for pts w/ noninfected AD.2
- Don’t recommend: prebiotics/probiotics, routine dust mite covers, specific laundering techniques/products;5 also don’t use: topical antihistamines, antimicrobials (although pts who are immunocompromised/immunosuppressed, w/ more-severe bacterial skin infxn, severe AD, or hx of severe infxns, or who want to avoid bacterial infxn complications may prefer adding antimicrobials to standard care1), or antiseptics,2 systemic abx in absence of clinically evident infxn,4 or systemic steroids (consider only for acute, severe exacerbations or as short-term bridge tx to other systemic, steroid-sparing tx).4
View epocrates drug info: Footnotes 1 AAAAI/ACAAI 2023. Chu DK, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2023 Dec 18:S1081-1206(23)01455-2. Free full-text PDF
2 AAD 2023. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jul;89(1):e1-e20. Full-text PDF
3 ESC 2017. Wong ITY, et al. Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Can Pharm J (Ott). 2017 May 30;150(5):285-297. Free full-text PDF at PubMed Central®
4 AAD 2023. Davis DMR, et al. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol. 2023 Nov 3:S0190-9622(23)02878-5. Full-text PDF
5 AAD4 2014. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33. Free full-text PDF at PubMed Central®
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Severe or refractory active dz
Basic skin care plus optimized TCS or TCI remains mainstay of care, but add photo-tx or systemic agent if unresponsive. - Basic skin care: Use moisturizers1,2 (may be applied soon after bathing);2,3 when using a moisturizer, consider its allergenic potential, palatability, heterogeneity in formulations and trial data, paucity of data in pts w/ skin of color, and cost;1,2 ointment-based may provide greater benefit for more-severe dz;1 avoid aggravating factors (e.g., long hot baths/showers; irritants such as soaps/cleansers, fragrances, wool, etc.);3 bathing is conditionally recommended for tx and maintenance in adults.2
- Optimize TCS in adults w/ AD;1,2 consider pt’s body area2 and lesion severity3 when selecting TCS: typically, lower potency in areas of thin skin (face, neck, genitals, skin folds);1-3 qd application may be sufficient for potent TCS;2 qd application of TCS may be as effective as bid (although bid may be considered for more-severe flare or pts who want quick resolution or respond better to bid1);3 monitor PE for cutaneous AEs (esp. skin atrophy); risk factors for atrophy include higher-potency TCS use, occlusion, use on thinner and intertriginous skin, older pt age, and long-term continuous TCS use; minimize periocular steroid use (even though association w/ cataracts or glaucoma is unclear);2 see epocrates’ Topical Corticosteroid Potencies tool.
- TCIs a steroid-sparing alternative;1-3 consider using to avoid skin atrophy, telangiectasia, striae on face, skin folds when low-potency TCS not effective;1 use tacrolimus 0.03% or 0.1% oint in adults;2 consider w/ periocular AD, where TCS may also ↑ risk of cataracts/glaucoma;3 however, TCIs may initially burn/itch (tacrolimus may cause local irritation, at least initially)1-3 and have black box warning for rare cutaneous CA and lymphoma risk2 (though causal relationship not established;3 also, several long-term studies suggest ↑relative risk of lymphoma w/ TCI use, but given the low absolute risk, CA risk isn’t likely clinically meaningful2); pts receiving combo of tacrolimus 0.1% oint and clocortolone pivalate 0.1% crm bid achieved significantly better dermatologic sum scores (measure excoriation, induration, and erythema) than pts receiving mono-tx w/ either agent.2
- Photo-tx: 2nd-line after failure of basic skin care, TCS, and TCI;1,3,4 can be used concurrently w/ topical agents as maintenance or rescue tx or to treat flares.4
- Systemic agents indicated when optimized topical tx and/or photo-tx don’t adequately control dz, or when dz severity substantially impacts QOL.1,3,4
- Strongly recommend: dupilumab, tralokinumab,1,4 abrocitinib, baricitinib, upadacitinib.4
- Conditionally recommend: cyclosporine modified,1,4 MTX, mycophenolate mofetil, azathioprine,4 abrocitinib, baricitinib, upadacitinib.1
- Conditionally recommend against: MTX, mycophenolate mofetil, azathioprine.1
- Insufficient data: systemic abx, PO antihistamines, montelukast, apremilast, ustekinumab, IVIG, interferon-γ, omalizumab, TNF-α inhibitors, systemic calcineurin inhibitors (other than cyclosporine), mepolizumab.4
- Avoid systemic steroids; consider only for acute, severe exacerbations or as short-term bridge tx to other systemic, steroid-sparing tx.4
- Oral JAK inhibitors: After considering risks and possible benefits, may use in adults and adolescents w/ moderate to severe AD refractory to or who can’t tolerate/use mid- to high-potency topical tx and systemic tx including a previously recommended biologic. AAAAI/ACAAI conditionally recommends replacing systemic tx w/ one of the following (in alpha order): abrocitinib 100-200 mg (≥12 yo); baricitinib 2-4 mg (not FDA approved for AD); upadacitinib 15-30 mg (≥12 yo). AAAAI/ACAAI conditionally recommends against azathioprine.1
- Consider sedating PO antihistamines for pruritis, esp. if sleep interrupted.3
- If eczema herpeticum: Use systemic antivirals.3
- Anti-staph tx not routine: AAD conditionally recommends against topical antiseptics for AD, but bleach baths or topical NaOCl may be suggested to ↓ dz severity in pts w/ moderate to severe AD w/ clinical signs of secondary bacterial infxn;2 AAAAI suggests bleach baths as additive tx for moderate to severe but not mild dz;1 can consider dilute bleach baths 2x/wk and intranasal mupirocin to ↓ AD severity, per AAAAI (esp. in pts w/ recurrent skin infxn);1 systemic abx also appropriate w/ clinically evident infxn.4
- Wet wrap tx (typically w/ low- or mid-potency TCS) is an effective option to control AD flares and mitigate recalcitrant dz; wet dressings are conditionally recommended in adults w/ moderate to severe AD experiencing a flare; require ↑effort and time, as well as pt education, to ensure correctness.2
- Structured pt education recommended as adjunct to tx:1 nurse-5 or pharmacist-led3 programs, video interventions can be considered.5
- Elicit hx of environmental, food, or contact allergies.1,5 AAD says to pursue testing only w/ concerning hx—e.g., in kids <5 yo w/ moderate/severe dz and hx of immediate reaction, consider testing for milk, egg, peanut, wheat, and soy allergy;5 however, AAAAI/ACAAI recommends against allergy testing for food elimination, as food removal in a sensitized but unexposed infant could increase risk of developing IgE-mediated food allergy. Also, risk for malnutrition would favor against pursuing an elimination diet.1 Don’t base food elimination diets solely on test results.1,5
- SLIT/SCIT: AAAAI/ACAAI conditionally recommends as adjunct for pts w/ moderate to severe dz refractory to or who can’t tolerate/use midpotency topicals, and conditionally recommends against for mild dz; however, may benefit allergic comorbidities, even in mild AD, where net benefit is small.1
- Insufficient evidence: fish oils, evening primrose oil, borage oil, multivitamins, zinc, vit D, vit E, vit B12 and B6, special clothing fabrics, Chinese herbal meds, massage tx, aromatherapy, naturopathy, hypnotherapy, acupressure, or autologous blood injections.5
- Limited available evidence: use of a particular moisturizer or active ingredient in an emollient; a standard for the frequency or duration of bathing, temp of water, type of soap, and use of water softeners, and other bathing accessories, including bleach, for pts w/ noninfected AD.2
- Don’t recommend: prebiotics/probiotics, routine dust mite covers, specific laundering techniques/products;5 also don’t use: topical antihistamines, antimicrobials (although pts who are immunocompromised/immunosuppressed, w/ more-severe bacterial skin infxn, severe AD, or hx of severe infxns, or who want to avoid bacterial infxn complications may prefer adding antimicrobials to standard care1), or antiseptics,2 or systemic abx in absence of clinically evident infxn.4
View epocrates drug info: Footnotes 1 AAAAI/ACAAI 2023. Chu DK, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2023 Dec 18:S1081-1206(23)01455-2. Free full-text PDF
2 AAD 2023. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jul;89(1):e1-e20. Full-text PDF
3 ESC 2017. Wong ITY, et al. Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Can Pharm J (Ott). 2017 May 30;150(5):285-297. Free full-text PDF at PubMed Central®
4 AAD 2023. Davis DMR, et al. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol. 2023 Nov 3:S0190-9622(23)02878-5. Full-text PDF
5 AAD4 2014. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33. Free full-text PDF at PubMed Central®
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Moisturizers are integral to long-term maintenance. While prn topical anti-inflammatories (TCS, TCI) may suffice, some pts benefit from intermittent regular use. - Basic skin care: Use moisturizers1-3 (may be applied soon after bathing);3,4 when using a moisturizer, consider its allergenic potential, palatability, heterogeneity in formulations and trial data, paucity of data in pts w/ skin of color, and cost;1,3 ointment-based may provide greater benefit for more-severe dz;1 avoid aggravating factors (e.g., long hot baths/showers; irritants such as soaps/cleansers, fragrances, wool, etc.);4 bathing is conditionally recommended for tx and maintenance in adults.3
- Proactive, topical anti-inflammatory reduces flares: Use medium-potency TCS (e.g., fluticasone propionate 0.05% crm) intermittently as a maintenance tx (2x/wk) in adults w/ AD to ↓ dz flares and relapse; maintenance in between AD flares w/ TCS (1-2x/wk) or TCI (2-3x/wk) applied to previously affected skin;1-4 reactive prn use may suffice for some.2,4
- Structured pt education recommended as adjunct to tx:1 nurse-2 or pharmacist-led4 programs, video interventions can be considered.2
- Elicit hx of environmental, food, or contact allergies.1,2 AAD says to pursue testing only w/ concerning hx;2 however, AAAAI/ACAAI recommends against allergy testing for food elimination, as food removal in a sensitized but unexposed infant could increase risk of developing IgE-mediated food allergy. Also, risk for malnutrition would favor against pursuing an elimination diet.1 Don’t base food elimination diets solely on test results.1,2
- Insufficient evidence: fish oils, evening primrose oil, borage oil, multivitamins, zinc, vit D, vit E, vit B12 and B6, special clothing fabrics, Chinese herbal meds, massage tx, aromatherapy, naturopathy, hypnotherapy, acupressure, or autologous blood injections.2
- Limited available evidence: use of a particular moisturizer or active ingredient in an emollient; a standard for the frequency or duration of bathing, temp of water, type of soap, and use of water softeners, and other bathing accessories, including bleach, for pts w/ noninfected AD.3
- Don’t recommend: prebiotics/probiotics, routine dust mite covers, specific laundering techniques/products;2 also don’t use: topical antihistamines, antimicrobials (although pts who are immunocompromised/immunosuppressed, w/ more-severe bacterial skin infxn, severe AD, or hx of severe infxns, or who want to avoid bacterial infxn complications may prefer adding antimicrobials to standard care1), or antiseptics.3
View epocrates drug info: Footnotes 1 AAAAI/ACAAI 2023. Chu DK, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations. Ann Allergy Asthma Immunol. 2023 Dec 18:S1081-1206(23)01455-2. Free full-text PDF
2 AAD4 2014. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis: Part 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33. Free full-text PDF at PubMed Central®
3 AAD 2023. Sidbury R, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2023 Jul;89(1):e1-e20. Full-text PDF
4 ESC 2017. Wong ITY, et al. Guidelines for the management of atopic dermatitis (eczema) for pharmacists. Can Pharm J (Ott). 2017 May 30;150(5):285-297. Free full-text PDF at PubMed Central®
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