Atopic dermatitis (AD) is a chronic inflammatory skin disorder with a trend of increasing incidence. Because of its complex etiology, long course, and difficulty in treatment, each country and region has developed appropriate guidelines for diagnosis and treatment according to national conditions.
Definition
Five guidelines define AD as an inflammatory, pruritic, chronically recurrent skin disease, often with a personal or family history of allergic diseases such as bronchial asthma and allergic rhinitis conjunctivitis. However, the JDA guidelines define AD as a recurrent eczema-like skin disease with pruritic and inflammatory features, accompanied by physiological skin dysfunction (e.g., dryness, barrier disruption), and most patients have atopic qualities.
Main treatment methods
It is very important to integrate the treatment according to the severity of the disease, and the treatment is divided as follows.
1.Basic treatment
The 6 guidelines jointly agree that adequate and sufficient use of moisturizers is an important basic treatment that can reduce the amount of hormones, help restore the skin barrier, relieve pruritus, prevent recurrence, and keep the disease stable. Specifically, it is generally used after topical topical glucocorticosteroids are relieved in the acute stage, at least twice a day, and moisturizers are more effective when used in the slightly wet state after bathing.
2, avoid allergens, aggravating factors
For food allergens, common allergenic foods are milk, eggs, cereals, nuts. Detection methods are dot prick test, serum specific IgE, APT (atopy patch test). The prick test is associated with an immediate reaction, the atopy patch test is associated with a delayed reaction, which improves the accuracy of the test, and the serum specific IgE more accurately measures the components of food allergy.
The most important inhaled allergens are dust mites, animal fur, and pollen. Testing methods include the puncture test, APT, and specific IgE. guidelines recommend: avoiding specific inhalant allergens such as pollen and animal fur; maintaining a clean living environment; and using covers to reduce exposure to house dust mites. The allergen with the most evidence for treatment is dust mites.
Common contact allergens are metals, perfumes, neomycin, lanolin, etc. Exposure to items containing these components should be reduced. Patients with AD should avoid jobs that are damaging to the skin or that expose them to strong allergens, such as hairdressers, cleaners, metal workers, nurses, and other professions.
Avoid possible irritants, such as scratching, scalding, irritating textiles and overly tight clothing. Maintain a suitable ambient temperature. It is gratifying to note that the ETFAD/EADV guidelines list several careful avoidance strategies or beneficial measures: use of vacuum cleaners, insecticides, use of covers, wearing soft clothing, avoiding smoking, cool room temperature, using more moisturizers in winter, vaccination in rash-free areas, breastfeeding until April as much as possible, ventilating homes, using fewer carpets, mopping with sponges, not using toys containing lint, not having pets, closing windows during pollen season, etc. Close windows during pollen season.
3. Topical anti-inflammatory drugs
Six guidelines agree that topical glucocorticoids are the first-line therapy for AD, and that topical calcium-modulated neurophosphatase inhibitors are safe and effective in treating AD and have unique advantages.
Specific usage and optimization measures regarding the two classes of anti-inflammatory drugs, etc., are outlined below.
(1) Glucocorticoids: Different types and strengths of agents should be selected according to age, weight, site and condition. Weak or medium-acting glucocorticosteroids are used on the face, genital area, folds, and in children. Local topical glucocorticosteroids should be used 1-2 times a day during the acute stage, and the dosage should be gradually reduced after the inflammation is controlled. The presence of rebound should be judged by changing to once a day or once every other day, and then to weak-acting hormones or hormone-free preparations to avoid rebound due to too rapid discontinuation of the drug.
Pruritus is the most important symptom to judge the efficacy, and if itching is obvious, the treatment should be maintained. For moderately severe pediatric patients, start with a glucocorticoid hormone of a slightly lower grade than its adult counterpart, and then use a stronger grade if it is not effective. The face is usually administered for less than 1 week, after which it is changed to intermittent therapy. The standardized use has few adverse effects, and the guidelines recommend newer drugs such as mometasone furoate, fluticasone, and prednisolone.
Intermittent therapy is recommended: the use of strong glucocorticosteroids to control the disease and then switch to weak agents, combined with moisturizers, long-term intermittent medication is safe and effective. The guidelines recommend active therapy: long-term low-dose anti-inflammatory drug treatment (twice a week) combined with moisturizers during the stable period can effectively reduce relapses, such as fluticasone cream, etc.
(2) Calcium-modulated neurophosphatase inhibitors: These drugs are important for the treatment of AD and are effective for both short-term and long-term use, including tacrolimus ointment and pimecrolimus cream. Tacrolimus ointment is recommended for active therapy and is effective in preventing relapse when used twice a week in remission. The advantage of these drugs is that there is no skin atrophy at the site of application, especially for wrinkled, thin areas, and they can be used for a long time. The most common side effect is a transient burning and irritation sensation, which usually starts within 5 minutes of application and can last for up to 1 hour, and disappears within 1 week of application. Guidelines suggest that there is no evidence that topical TCI increases the risk of malignancy and viral infection.
4. Oral antihistamines
The guidelines jointly point out that first-generation antihistamines with sedative effects can effectively relieve pruritus in AD and are superior to second-generation antihistamines.
5. Antibacterial and antifungal therapy
Guideline consensus: AD patients with impaired skin barrier are prone to secondary infections, most commonly Staphylococcus aureus, and other pathogens such as streptococci and fungi. For patients with concomitant infections, antibacterial agents or antifungal drugs should be applied systemically or topically. Topical antimicrobials are generally recommended for less than 2 weeks and systemic use for 7-10 days. The guidelines recommend topical topical triclosan, chlorhexidine, and fusidic acid. Triclosan and chlorhexidine have low resistance and low irritation, while fusidic acid has low MIC value and good permeability. Chinese guidelines and ETFAD/EADV guidelines recommend the combination of topical glucocorticoids and antimicrobials for patients with bacterial colonization.
6. Antiviral therapy
The AD guidelines and the Chinese guidelines do not mention anything about this. The other four guidelines agree that systemic antiviral therapy should be given immediately to patients with AD who develop herpes-like eczema.
7.Phototherapy
NB-UVB and UVAl are more effective. Phototherapy is preceded by topical glucocorticoids and emollients. The general treatment is 3-5 times/week for 6-12 weeks. UV is less effective for hairy and wrinkled areas.
8.Systematic use of anti-inflammatory drugs
Guideline consensus: systemic application of glucocorticoids is only used for a short time for severe AD or acute phase. For severe patients with treatment resistance, immunosuppressants may be used as appropriate. The drug with more clinical evidence is cyclosporine A.
9. Biologic agents
All guidelines suggest that no biologic agents have been approved for AD treatment. Only patients with severe treatment resistance may be considered for trial use.
10.Health education and psychological counseling
The guidelines agree that health education and psychotherapy are very useful and essential elements of AD treatment, which can help to understand the disease, improve patient compliance, develop good habits, and develop psychological coping skills in order to obtain better treatment results and improve quality of life. Psychological treatment should be individualized.
Conclusion.
AD is a chronic skin disease and a comprehensive treatment plan should be determined with an eye to long-term management. Condition assessment is the basis for choosing a treatment plan. Active maintenance therapy is receiving increasing attention, and intermittent treatment with TCS or TCI plus adequate use of emollients can effectively reduce the disease and delay relapse. Health education and psychological counseling are important to achieve good outcomes. Foreign guidelines all refer to a large amount of evidence from the evidence-based medical literature, while Chinese guidelines are relatively lacking in domestic evidence-based medical evidence. Different guidelines add some practical value in terms of ideas, usage and precautions. Based on the data from clinical studies, it is more objective and reliable to use evidence-based medicine to arrive at recommendations.