The Goals of Treatment for Atopic Dermatitis and Key Updates on Its Therapeutic Recommendations

Atopic Dermatitis (AD) is a chronic, pruritic inflammatory skin condition that typically affects the face (cheeks), neck, arms, and legs but usually spares the groin and Axillary regions. AD usually starts in early infancy, but also affects a substantial number of adults. AD is commonly associated with elevated levels of Immunoglobulin E (IgE). That it is the first disease to present in a series of allergic diseases—including food allergy, asthma, and allergic rhinitis, in order—has given rise to the “Atopic march” theory, which suggests that AD is part of a progression that may lead to subsequent allergic disease at other epithelial barrier surfaces.

Persistent pruritus (itchiness) is the main symptom of AD. The disease typically has an intermittent course with flares and remissions occurring, often for unexplained reasons.

Primary physical findings include the following:

• Xerosis (dry skin)
• Lichenification (thickening of the skin and an increase in skin markings)
• Eczematous lesions (skin inflammation)

The eczematous changes and its morphology are seen in different locations, depending on the age of the patient (i.e., infant, child, or adult).

The following is a group of symptoms and features commonly seen in AD:

• Pruritus
• Early age of onset
• Chronic and relapsing course
• IgE reactivity
• Peripheral eosinophilia
• Staphylococcus aureus superinfection
• Personal history of asthma or hay fever or a history of Atopic diseases in a first-degree relative

To add more on recent therapeutic options in adult Atopic Dermatitis (Till now it was mainly considered as disease of Infants and childhood mainly, we have seen recent shift to adult AD also)

Points to Ponder:

• Although AD is not a life-threatening disease, it brings severe disruption to the quality of life of older patients with AD, who are in their 80+. Oral Corticosteroids, Oral Cyclosporine & Oral Methotrexate are useful medicines to take care of Skin Lichenification and troublesome skin pruritus. Adjutant therapy of mid-potency topical Corticosteroids, Barrier protector cream/lotion and topical Moisturizers plays a significant role after oral therapy is taken by patients.
• Avoidance of Skin irritants and allergens like perfumes, anti-bacterial soap, detergents, topical perfumed oils, Avoidance of dairy products especially milk-products should be considered in management of AD in older age group patients, without testing food allergy tests, which have low specificity and sensitivity.

Based on our clinical experience and literature here are our recommendations for Management of Atopic Dermatitis:

• The goals of treatment for Atopic dermatitis are to reduce symptoms (pruritus and dermatitis), prevent exacerbations, and minimize therapeutic risks.
  
• The optimal management requires a multipronged approach that involves the elimination of exacerbating factors, restoration of the skin barrier function and hydration of the skin, patient education, and pharmacologic treatment of skin inflammation.
  
• We suggest that patients with mild to moderate atopic dermatitis be initially treated with topical corticosteroids and emollients. The choice of the corticosteroid potency should be based upon the patient's age, body area involved, and degree of skin inflammation:
  
• For patients with mild Atopic dermatitis, we suggest a low-potency: groups 5 and 6 corticosteroid cream or ointment eg, Desonide 0.05%, Hydrocortisone 2.5%. Topical corticosteroids can be applied once or twice daily for two to four weeks.
  
• For patients with moderate disease, we suggest medium- to high-potency: groups 3 and 4 corticosteroids (eg, Flucinolone 0.025%, Triamcinolone 0.1%, Betamethasone dipropionate 0.05%.
  
• The face and skin folds are areas that are at high risk for atrophy with corticosteroids. Initial therapy in these areas should start with a low-potency corticosteroid such as Desonide 0.05% ointment for up to three weeks.
  
• We suggest that patients with AD involving the face or skin folds that is not controlled with topical corticosteroids be treated with a topical calcineurin inhibitor (ie, Tacrolimus or Pimecrolimus)
  
• We suggest proactive therapy to prevent relapse in adolescents and adults with moderate to severe Atopic dermatitis that responds to continuous therapy with topical corticosteroids or calcineurin inhibitors. We suggest medium- to high-potency topical corticosteroids rather than topical calcineurin inhibitors for proactive, intermittent therapy of Topical corticosteroids are applied once daily for two consecutive days per week for up to 16 weeks.
  
• We suggest Dupilumab, rather than conventional immunosuppressant agents, for patients with moderate to severe disease unresponsive to topical therapy alone for whom phototherapy is not feasible or acceptable Dupilumab is also an option for patients who are not candidates for or failed previous treatment with conventional immunosuppressive agents.
  
• Dupilumab, phototherapy, and conventional immunosuppressive agents are not suitable for infants and young children.

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