New AD guidelines focus on topical and prescription agents

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By Lawrence F. Eichenfield, MD

Earlier this month, two new atopic dermatitis (AD) guidelines were published in the Journal of the American Academy of Dermatology. These evidence-based guidelines are sections two and three of a four-part series on the care and management of AD and focus on over-the-counter and prescription topical treatment options, as well as more potent prescription agents.

These new guidelines, developed by the AAD Clinical Guidelines Work group, update our previous clinical guidelines of care for AD, which were last published in 2004. The work group, which I co-chair along with Robert Sidbury, MD, thoroughly analyzed new data to develop updated and expanded recommendations for the diagnosis, assessment, and treatment of AD. When complete, the Academy will have a four-part guideline series for this chronic and often debilitating condition.

First-line therapies

For patients with AD, the guidelines recommend the following as first-line therapies:  

Moisturizers 

  • Moisturizers are an essential part of treatment for patients with AD, even those with moderate and severe AD.
  • Patients should choose a moisturizer that is free of additives, fragrances, and perfumes.
  • Since there is currently not any scientific evidence that demonstrates how often to apply moisturizer or how much to apply to achieve optimum benefits, patients should apply and reapply as much moisturizer as they feel is necessary to achieve relief.

Bathing

  • While there is little evidence to support a standard bathing frequency or duration, it is generally suggested that patients bathe up to once a day for 5 to 10 minutes in warm water followed by applying a moisturizer.
  • Patients should use non-soap cleaners that have a neutral to low pH, are hypoallergenic, and fragrance-free.  
  • Bleach baths are recommended when there are visible signs of infection.  

Wet wrap therapy

  • Wet wrap therapy is recommended to quickly reduce patients’ AD flares. 
  • Wet wraps help increase the penetration of moisturizers and prescription topical medications, decrease water loss as well as provide a physical barrier against scratching.
  • To apply a wet wrap, patients should moisturize their skin, and then wrap the skin in a layer of wet bandages, gauze, or cotton suit. A dry layer is then applied over the wet dressings.

Topical corticosteroids (TCS)

  • Can be used to treat active inflammation and itch, and to prevent future disease flares.
  • TCS are available over-the-counter and in increasing prescription strengths as well as in several forms. The dermatologist will determine the appropriate TCS selection for each patient.  

Topical Calcineurin Inhibitors (TCI)

  • May be prescribed for patients with AD who have not found relief through first-line treatments.
  • Can be used to treat active inflammation and itch, and to prevent future disease flares.
  • TCI include tacrolimus or pimecrolimus.
  • Patients, including those under 2 years of age, can use this treatment off-label under the guidance of their dermatologist.

While the FDA has placed a black box warning on TCI stating that there is a lack of long-term safety data about the potential risk of cancer, such as skin cancer and lymphoma, patients should know that studies have not demonstrated an increased cancer risk from TCI use.

Severe AD requires stronger prescription treatment

For patients with severe AD who have been unable to control their symptoms using first-line therapies, the Academy guidelines recommend the following treatments:

Phototherapy

  • Ultraviolet (UV) light may be prescribed to treat patients with acute AD or as a maintenance therapy. Ultraviolet B (UVB), ultraviolet A (UVA), or a combination of UVB and UVA may be used during therapy.
  • Phototherapy can be used alone or in combination with TCS and moisturizers.
  • While phototherapy can be very effective, it can be difficult for patients to go to a hospital or medical clinic two to three times a week as required for this treatment. If this is a significant obstacle to treatment, patients can discuss the use of home phototherapy units with their dermatologist as a convenient and cost-effective option. 

Systemic immunomodulators

  • For patients who do not achieve adequate control of their disease through topical therapies or phototherapy or for those who have been unable to control their symptoms despite adherence to recommended treatment plans.  
  • These therapies may also be used when a patient’s AD negatively affects their medical, physical, and emotional well-being, especially if it impacts work, school performance, or interpersonal relationships.
  • Used off-label for treating AD.
  • Scientific data demonstrates that cyclosporine, methotrexate, mycophenolate, and azathioprine can be effective treatments for unresponsive AD.
  • Once disease is better controlled, use of systemic immunomodulators is slowly decreased. Control of AD is maintained through moisturizers, topical therapies, and/or phototherapy.    

Use of non-recommended treatment options may delay effective treatment

While the guidelines specify many treatments that are recommended for patients with AD, treatments that have not been shown to benefit patients are also highlighted.  

Our patients often ask us about other treatments they have heard can be beneficial for their AD. Treatments that are not supported by evidence-based research are noted in the guidelines as their use may delay patients in getting effective treatment, or even make their disease worse. We also note therapies where we do not have enough data to make a recommendation. For example, while biologics have shown to be effective for the treatment of psoriasis, there is not enough research to support a recommendation for or against their use in the treatment of AD at this time.

Other treatments that are not recommended for patients with AD include:

  • Systemic corticosteroids, as they have the potential for short- and long-term health risks and frequently lead to AD flares upon discontinuation. These flares can be worse than the initial flare that the therapy was trying to treat.   
  • Topical antihistamines should not be used as an AD treatment, and non-sedating antihistamines are not recommended unless there are other atopic or other allergic conditions being treated.  
  • Unless there are signs of a bacterial infection, systemic antibiotics are not recommended.
  • Topical antimicrobial and antiseptic treatments, such as antibacterial soaps or bath additives, are not recommended for treating AD.  

Part 1 of the guidelines was published in the February 2014 issue of JAAD and focused on the diagnosis and assessment of individuals affected by AD. Part 4 in the series, which is still in preparation, will discuss the prevention of disease flares and the use of adjunctive therapies. 

Dr. Eichenfield is Chief of Pediatric and Adolescent Dermatology at both Rady Children's Hospital, San Diego, and at University of California, San Diego School of Medicine. He is also professor of clinical pediatrics and medicine (dermatology) at UCSD.

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