WAIKOLOA, HAWAII – The 2014 update of the American Academy of Dermatology guidelines on atopic dermatitis take a strong stance in favor of the use of topical calcineurin inhibitors as topical corticosteroid-sparing agents, even in children less than 2 years old, where the use of the medications remains off-label.
The evidence-based AAD guidelines bestow a Class A, Level of Evidence I recommendation for the use of topical calcineurin inhibitors as topical steroid-sparing agents. The proactive use of topical calcineurin inhibitors as proactively scheduled, short-term, intermittent maintenance therapy to prevent disease flares also gets an A-I recommendation in the guidelines. The report states that there is no need to monitor blood levels of topical calcineurin inhibitors, Dr. Wynnis Tom noted at the Hawaii Dermatology Seminar, sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.
Dr. Wynnis Tom
The guidelines emphasize the importance of having a proactive discussion with the patient and/or parents about the black box warning for topical calcineurin inhibitors, stressing the fact that interim analyses of long-term surveillance studies do not show an increase in malignancies, said Dr. Tom, a member of the working group that developed the AAD guidelines and a pediatric dermatologist at the University of California, San Diego.
The section of the guidelines devoted to topical therapies includes a detailed description of wet wrap therapy, which is useful for quickly reducing atopic dermatitis severity during flares. The use of topical antihistamines gets a strong thumbs-down in the guidelines.
The guidelines go into considerable detail about the importance of fixing the skin barrier. Bathing is recommended as an important component of therapy, with the caveat that there is no good evidence as to the optimal frequency or duration.
"You want to get the crusting off and hydrate the skin; but you do have to be careful of how long the bath lasts, because you don’t want the skin to dry out as the water evaporates," Dr. Tom said. "I find bathing even daily is good, so long as people are using moisturizers afterward. That’s the key part both for treatment and maintenance: liberal use of moisturizers."
The guideline panel determined that while moisturizers are a cornerstone of atopic dermatitis therapy, no one moisturizer product has been shown to be better than the others. And that includes the prescription devices containing ceramides or hydrolipids, which haven’t persuasively been shown to have clinical advantages over inexpensive over-the-counter moisturizers.
The 2014 atopic dermatitis guidelines are the first-ever AAD guidelines to include an entire section devoted to the diagnosis of a dermatologic disorder (J. Am. Acad. Dermatol. 2014;70:338-51). This was deemed necessary because misdiagnosis of atopic dermatitis is a problem, particularly in adults.
The guidelines stress that atopic dermatitis is a clinical diagnosis that requires ruling out conditions including contact dermatitis, cutaneous T-cell lymphoma, psoriasis, photosensitivity reactions, seborrheic dermatitis, and immune deficiency diseases. At this time, no specific biomarkers can be recommended for the diagnosis of atopic dermatitis or assessment of its severity. In particular, according to the guidelines, the popular practice of monitoring immunoglobulin E levels isn’t recommended.
The comprehensive guidelines also include a section on phototherapy and systemic agents. In addition, a section on preventing disease flares and the use of adjunctive therapies is slated for release in June.
Dr. Tom reported serving as a financially uncompensated investigator for studies sponsored by Amgen and Anacor. SDEF and this news organization are owned by the same parent company.