Guidelines for Management of Atopic Dermatitis — Part IV: Prevention of Disease Flares and Use of Adjunctive Therapies and Approaches

Guideline Watch |
October 21, 2014

Guidelines for Management of Atopic Dermatitis — Part IV: Prevention of Disease Flares and Use of Adjunctive Therapies and Approaches

  1. Craig A. Elmets, MD

Recommendations to direct AD management and aid patient counseling in the use of valid measures to prevent flares

  1. Craig A. Elmets, MD

Sponsoring Organization: American Academy of Dermatology (AAD)

Target Population: Primary care providers, dermatologists, allergists, and pediatricians

Background and Objective

Atopic dermatitis (AD) is a chronic inflammatory skin disease prone to exacerbations and remissions. Comprehensive management requires procedures to prevent disease flares. This fourth and final part of the AAD guidelines for the management of atopic dermatitis addresses currently available evidence on preventing flares. Other parts of the AAD atopic dermatitis guidelines have been reviewed previously (see NEJM JW Dermatol Feb 21 2014 and Jun 11 2014).

Key Points

  • Topical moisturizers provide skin hydration and some may improve epidermal barrier dysfunction. They have minimal side effects and are an important component of AD management.

  • Disease flares and relapse can sometimes be averted by continued application of topical corticosteroids (1–2 times per week) or calcineurin inhibitors (2–3 times per week) to currently and previously involved skin. However, prolonged use can cause hypothalamic–pituitary–adrenal axis suppression.

  • Educational interventions (information about pathogenesis, use of therapeutic modalities, and realistic management goals) have been shown to help prevent flares and relapses. Organizations such as the National Eczema Association (http://nationaleczema.org) usefully add to physician- and nurse-led instruction.

  • Food allergy testing is not routinely recommended. Positive reactions poorly correlate with provocation of dermatitis on exposure. In individuals with suspected food-provoked flares, food diaries may identify specific dietary agents. Milk elimination and elemental or few-food diets have not been of benefit in unselected populations. Egg-free diets may be helpful in infants with IgE-specific egg antibodies and evidence of flares after egg exposure.

  • Contact allergies are clinically indistinguishable from AD and should be considered after appropriate therapy fails.

  • Little evidence supports use of probiotics, essential fatty acid-rich diets, or fish oil. Evidence is insufficient to assess the value of vitamin and mineral supplementation.

  • Only one study demonstrated value from avoidance of house dust mites. Special pillow and mattress covers may be employed in patients not benefitting from other measures. House dust mite immunotherapy is being evaluated, but it is too early to determine its role in AD management.

Comment

A number of interventions have been proposed to treat or prevent AD exacerbations; these are well publicized in consumer media. AD patients and families have often heard of these and frequently have questions about which are valid or discredited. This guideline provides recommendations that can usefully direct AD management and aid patient counseling in the use of such measures.

Dr. Elmets was a member of the working group that prepared these guidelines for the American Academy of Dermatology.

Editor Disclosures at Time of Publication

  • Disclosures for Craig A. Elmets, MD at time of publication Consultant / Advisory board Astellas Pharmaceuticals Grant / Research support NIH; NIH/NCI; Veteran’s Administration; Ferndale Laboratories; Abbvie Editorial boards Cancer Prevention Research; Photodermatology, Photoimmunology, & Photomedicine; UpToDate; eMedicine; Journal of Dermatological Sciences Leadership positions in professional societies American Academy of Dermatology (Chair, Clinical Guidelines and Research Committee); Photomedicine Society (Board of Directors)

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