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Guidelines

Treatment guidelines for AD

Overview

Guidelines provide a starting point for AD management based on the available evidence 12

  • Management should be individualized to the patient 12
  • The treatment strategy should be based on disease severity 1–3
  • Daily care with cleansing, bathing and emollient use is the mainstay of AD management across all disease severities. 1–3


International guidelines recommend a step-wise approach to AD care in adults and paediatric patients.

Guidelines for active treatment

International guidelines on AD, available from Europe (with committee members from Germany, Spain, Italy, Switzerland, Denmark, Poland, Hungary, France, Austria, Croatia and the Netherlands), the US (with committee members from 12 states in the US plus one from Canada and one from the UK), Latin America (with AD experts from Bolivia, Brazil, Colombia and Mexico) and Asia Pacific (with AD experts from Australia, Hong Kong, India, Indonesia, Malaysia, the Philippines, Singapore and Taiwan), are summarised in the figure below.

Overview of international guidelines for the management of AD

Microsoft Word - LOC APPROVAL

TCS, topical corticosteroid; TCI, topical calcineurin inhibitor; PUVA, psoralen and ultraviolet A; UVA/UVB, ultraviolet A/B
Adapted from 1–5 Ring J Eur Acad Dermatol Venereol 2012 (Part I and II) 14; Rubel J Dermatol 20133; Eichenfield J Am Acad Dermatol 20142; Sanchez J Revista Alergia México 2014 5

EU recommendations 
for use of TCSs in adults with AD1






 
  • TCSs are important first-line anti-inflammatory agents, resulting in a significant improvement in skin lesions versus placebo,particularly during the acute phase
  • Efficacy can be improved with the use of wet wraps
  • Proactive treatment with TCSs (twice weekly application of a small amount) may help reduce relapses
EU recommendations for use of TCSs in paediatric patients with AD1



















 
  • TCSs are used for uncontrolled disease after the use of skincare and emollient therapy alone
  • A small amount applied 2–3 times weekly (mean monthly amount 15g in infants >3 months and 30g children >12 years) concomitant with emollient use should enable maintenance of SCORAD values below 15–20
  • Standard topical application of TCSs may not be appropriate or tolerated by children with severe symptoms; wet wraps may be a more practical approach
  • A tapering treatment strategy is recommended for the use of TCSs in paediatric patients
  • There are few data to support the use of other therapies in the paediatric population
  • Use of systemic therapies, such as oral steroids, in children should be approached with caution
US recommendations for use of TCSs in adults with AD 2
  • TCSs are applied directly as first-line anti- inflammatory therapy onto the inflamed skin according to need
  • For acute flares, use TCSs daily until there is an improvement in inflammatory lesions
  • Twice daily use of TCSs is generally recommended and is the most common clinical practice
  • Continuous application of TCSs for long periods of time should be avoided
  • For maintenance therapy, apply TCSs once to twice weekly at site of repeated flares
  • Application sites should be assessed regularly for side effects
  • Counselling is recommended to address patient fears and incorrect beliefs

The US guidelines do not detail the management of AD in children, although they do provide some guidance on aspects of treating children with topical therapies, particularly in relation to safety. 6

US recommendations for use of TCSs in paediatric patients with AD 2
  • TCSs may be used for uncontrolled disease after the use of skincare and emollient therapy alone
  • TCSs are a mainstay of AD therapy in children
  • Consideration should be given to the potential for systemic and topical side effects, particularly in children
  • Short course mid- or high-potency TCSs may be appropriate to rapidly control symptoms
    		•

     

    Guidelines for preventative treatment

    Topical corticosteroids (TCSs) are effective for the prevention (and treatment) of flares 3

    International recommendations for the use of TCS for prevention of flares


     
    • For acute flares, TCSs are recommended daily until the inflammatory lesions significantly improve 2
    • Following disease control, guidelines recommend flare prevention with application of TCSs 1–2 times per week at the body site where the flare presented. 1–3

    Treatment guidelines for psoriasis

    • Treatment of psoriasis should be tailored to the individual patient need, taking into consideration: 7
      • Disease location and type
      • Characteristics of the psoriasis, including lesion thickness, degree of erythema and amount of scaling
      • Extent of disease
      • Quality of life
      • Co-morbidities
      • Patient’s situation and preferences
      • Response to prior treatments
    • Non-medicated topical moisturisers are an internationally recognized standard adjunctive treatment for psoriasis and should be used continuously even when symptoms are well-controlled 7
    • Topical corticosteroids are recommended as first-line therapy to treat psoriasis, and remain a mainstay of psoriasis treatment. The most potent and efficacious topical corticosteroids are approved for only short-term treatment (2–4 weeks) 7

    International guidelines for the treatment of psoriasis, available from Europe, the UK (NICE) and the US and are summarised in the table below.

    Overview of international guidelines for the management of psoriasis 7–11

    Limited disease Extensive disease

    First-line therapies

    Topical therapies:

    • Topical corticosteroids
    • Vitamin D and analogues
    • Dithranol
    • Tar preparations

    Second-line therapies

    • Phototherapy – UVB and UVA
    • Systemic non biological agents

       

    Third-line therapies

    • Systemic biological therapies



       
    US recommendations for use of TCSs in psoriasis 7















     
    • Around 80% of patients with psoriasis have mild to moderate disease, most of whom can be treated effectively with topical agents
    • TCSs are the cornerstone of treatment for the majority of patients with psoriasis, particularly those with limited disease
    • TCSs can be used as monotherapy once or twice daily or combined with other topical agents, UV light, or systemic agents
    • Due to the risk of side effects, the use of class I TCSs should be limited to no more than 2–4 times a week (maximum 50g/week), with a gradual reduction in use following clinical response
    • The potential for systemic and local side effects with TCS use may be greater in children than in adults

    References:

    1. Ring J, et al. J Eur Acad Dermatol Venereol 2012;26:1045–60
    2. Eichenfield L, et al. J Am Acad Dermatol 2014;71:116–32
    3. Rubel D, et al. J Dermatol. 2013;40:160–71
    4. Ring J, et al. J Eur Acad Dermatol Venereol 2012;26:1176–93
    5. Sanchez J, et al. Revista Alergia México 2014; 61:178–211
    6. Eichenfield L, et al. J Am Acad Dermatol 2014;70:338–51
    7. Menter A, et al. J Am Acad Derm 2009;60:643–59
    8. NICE Clinical Guidelines CG153 (2014): The assessment and management of psoriasis. Available at: http://www.nice.org.uk/guidance/cg153 (Last accessed September 2015)
    9. Menter A, et al. J Am Acad Derm 2008;58:826–50
    10. Menter A, et al. J Am Acad Derm 2010;62:114–35
    11. Pathirana D, et al. JEADV 2009;23:1–70

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