A consensus for treating atopic dermatitis

With new options becoming available, clearer guidelines on atopic dermatitis are a welcome development

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Management of atopic dermatitis needs to include repeated assessment of symptom severity on a verified scale, new guidelines recommend. 

Because no specific laboratory tests can provide a diagnosis or indication of symptom severity, assessment of atopic dermatitis has been largely subjective. However, the new dermatological advice is to consistently record patient-rated assessment of symptoms such as itch as part of a validated severity scale. 

The guidelines also suggest avoiding a one-off measure and instead repeatedly assess patients’ experience of severity to better track flares and treatment responses. 

But the decision to start systematic therapy is one that needs to be based on a holistic approach, not just a severity-based scoring system, doctors are advised. 

The consensus statement, which will be presented at the Australasian College of Dermatologists’ (ACD) Annual Scientific Meeting on the Gold Coast next weekend, was developed as a collaboration between dermatologists, immunologists, GPs, pharmacists and nurses.  

Speaking ahead of the conference, presenter and college fellow Associate Professor Saxon Smith said that there was currently no accepted set of guidelines around eczema in adults in the country.

“Many of the medications we use are essentially off-label,” he said. “There haven’t been large studies in eczema patients, but they have been used clinically for decades, with good effect.”

As a result, Professor Smith said they sought to marry the recent developments in the literature with the practical day-to-day experience of clinicians to establish some clear guidance, especially in light of the new targeted therapies for atopic dermatitis set to become more widely available. 

“New treatment options are starting to become available in Australia and in the world, and we need to have a really good grasp on how best to manage this and how these new medications may fit within that paradigm,” he said. 

While patients and their clinicians may have become nihilistic about the condition given the many decades where treatment recommendations and therapies remained largely the same, Professor Smith wanted people to know that there were options. 

For clinicians, the consensus statement will be presented with an algorithm that provides clear pathways for when to refer onto specialists. 

For patients with mild symptoms, the draft recommendation includes several weeks of initial therapy with topical corticosteroids and topical calcineurin inhibitors, and if treatment goals are not reached, or flares cannot be managed, to then refer onto a specialist. 

The draft recommendations include topical microbiome measures such as bleach baths and triclosan in the early stages.  

“If failure of therapy is due to lack of adherence and/or topical corticosteroid phobia, the first-line intervention of choice is patient education,” the draft suggests. And having them return to the clinic early and frequently can improve adherence, the experts recommend.  

The consensus document will also draw attention to the broad-reaching systemic and psychological impact of atopic dermatitis. Commonly associated conditions such as allergy, asthma and sensitivities to immune response should be investigated, they recommend. 

“The skin is only … the tip of the iceberg, for what else is happening in the body,” Professor Smith said.