Atopic Dermatitis Guideline Highlights Evidence-Based Treatment Strategies

A new clinical practice guideline on the management of atopic dermatitis (AD) in Japan has been created, providing clinicians with practical region-based recommendations that may have generalizable value to practitioners across the globe. The guideline was published in the Journal of Dermatology.

Researchers throughout the country worked in concert to examine treatment and management strategies of AD in the Japanese literature.

In addition to active topical and drug preparations for AD, the guideline highlights the importance of moisturizing the skin. According to the authors, research has demonstrated the superiority of twice-daily moisturizing over once-daily moisturizing as an adjunct to pharmacologic treatment for managing AD. Once remission with topical anti-inflammatory drugs has occurred, the guideline recommends that patients continue to follow a moisturizing regimen to ensure remission is maintained. Devising a combination strategy consisting of ≥2 topical products, such as a moisturizer and a topical steroid, should be performed only by a dermatologist or other specialized healthcare professional.

In cases in which eczema does not improve after the implementation of guideline-accordant treatment, patients should be referred to a specialist or specialized facility. Specialists should be considered when treated patients develop noticeable erythema, scratching-related scars, erosion, lichenification, or prurigo. Additionally, the guidelines suggest that patients be referred to a specialist when an infection by bacteria or a virus concomitantly occurs.

Complementary approaches and alternative medicine – strategies that fall outside of the care typically provided by a physician at a healthcare facility – are popular adjuncts to traditional AD therapy in Japan. A large proportion of hospitalizations for exacerbations of AD have been due to complications caused by inappropriate alternative medicine treatments. Poor compliance with standard medical therapy in place of alternative medicine also worsens disease. Although complementary treatment methods and alternative medicine have largely not been scientifically validated, a majority of patients with AD have tried such approaches. The guideline does not recommend complementary or alternative approaches due to this lack of evidence.

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Although the goal of drug therapy is to help patients with AD achieve early remission, severe cases of AD may warrant hospital care in conjunction with pharmacologic management. Patients who have an area of eruption that is extensive and who demonstrate acute exacerbation should be admitted to the hospital, the guideline authors state.

The value of hospital care is 3-fold. First, it allows for the use of intensive topical therapy with isolation from the external daily environment. Second, hospital care can help establish and cement a trust-based relationship between healthcare professional and patient, driving compliance to treatments and recommendations. Third, patients admitted to the hospital for severe AD can undergo a complete and thorough review of triggering factors, application methods, and skincare measures that may assist in the prevention of future exacerbations.

In the guideline, the goal of treatment adherence is consistently discussed, because all efforts of remission hinge on patients’ strict, everyday compliance with evidence-based therapy. Socioeconomic factors, as well as patient-, disease-, treatment-, and healthcare professional-related factors, can influence treatment adherence. In most cases, these factors can be targeted and modified, thus mitigating the risk for inadequate treatment adherence.

Business pressures and belief in medical or drug therapy are patient-related factors, whereas treatment-related factors include complex treatment methods and treatments that have a higher incidence of adverse reactions. Healthcare providers should discuss the evidence for each treatment approach to help patients understand each therapy’s utility in their disease. Additionally, patients should be made aware of any risks in an effort to ensure balanced and shared decision-making.

The guideline also emphasized the importance of patient education, for both inpatient and outpatient cases of AD. Patients and family members play an important role in the treatment of AD in patients treated with topical therapy in the outpatient setting. Family members, in addition to patients, should understand the clinical condition(s) and be able to comprehend the importance and application of the required treatment. The authors report that efforts in Japan that have assisted in patient and family AD education have been successful if performed by a multidisciplinary medical team. In addition, group work coordinated by a specialized nurse and online videos have proved to be helpful educational tools.

According to the guideline authors, patient education is paramount for improving adherence, particularly with topical steroids. In addition, the authors wrote that, “it is essential that the patient’s family properly understands the patient’s clinical conditions and the treatment required in order to improve adherence and achieve successful treatment.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

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Katoh N, Ohya Y, Ikeda M, et al. Clinical practice guidelines for the management of atopic dermatitis 2018. J Dermatol. 2019;46(12):1053-1101. doi: 10.1111/1346-8138.15090