A recently published European guideline (EuroGuiDerm) document provides clinicians with summarized evidence and recommendations on the use of systemic and nonsystemic treatments for atopic eczema. The new guideline was published in the Journal of the European Academy of Dermatology and Venereology.
The guideline committee made several recommendations regarding basic cleansing and emollient practices for the management of atopic eczema:
- Gentle cleansing and gentle bathing are recommended, particularly in acutely inflamed or superinfected skin.
- Bathing in moderately warm temperatures over a short duration is suggested.
- Alkaline soaps should not be used.
- Daily, frequent, and liberal use of emollients is recommended.
- Moisturizers with a hydrophilic formula are suggested for the summer, and moisturizers with a higher lipid content are suggested for the winter.
- Emollients should be applied immediately after bathing or showering along with soft pat drying of the skin.
- Emollients should be used as background treatment to prevent flares and reduce symptoms.
Recommendations are also made for the use of anti-inflammatory agents in atopic eczema management:
- Topical corticosteroids (TCS) and topical calcineurin inhibitors (TCIs) are recommended, with TCS recommended especially in acute flares.
- TCI can be used in areas of skin with a risk of atrophy due to TCS application.
- Topical corticosteroids are suggested as initial therapy prior to switching to a TCI to reduce the risk of stinging and burning of the skin.
- Proactive therapy comprising twice-weekly application with either TCS or TCI is recommended to reduce relapse risk and to improve disease control.
The guideline also included a section for recommendations on antimicrobial and antiviral treatments:
- A short course of systemic antibiotics is recommended in patients with extensive clinically superinfected lesions.
- Long-term application of topical antibiotics should be avoided, given the risk of resistance.
- Systemic antiviral treatment is recommended to treat eczema herpeticum.
- Topical antiseptic drugs are suggested in patients with a history of recurrent skin infections.
According to the guideline authors, itch represents a significant clinical symptom of atopic eczema. As such, recommendations were made on antipruritic treatment:
- Topical antihistamines should not be used for itch treatment.
- The panel provides a suggestion against first-generation systemic antihistamines as a long-term treatment for itch and second-generation systemic antihistamines as a treatment for itch.
- Ultraviolet (UV) therapy (UVB and UVA1) is suggested for the treatment of itch.
- The panel provides a suggestion against selective serotonin reuptake inhibitors as a treatment for itch.
The guideline panel also noted that photo(chemo)therapy is used in the management of moderate to severe atopic eczema recalcitrant to topical therapy. Recommendations for phototherapy and photochemotherapy included:
- Narrowband UVB and medium-dose UVA1 can be used for moderate to severe disease.
- The panel provides a suggestion for the use of narrowband UVB or UVA1 in pediatric patients; however, care should be made to avoid frequent and/or protracted treatment cycles.
- Balneophototherapy, UVAB, BB-UVB, and UVA can be considered as a second choice.
- The panel suggests PUVA therapy should only be used when prior phototherapy treatments were ineffective or when approved treatments are contraindicated, ineffective, or have led to adverse effects.
- The panel provides a suggestion for the use of topical emollients during phototherapy.
Given the association between food allergies with atopic eczema, the panel made some recommendations on dietary interventions:
- Providers should identify dietary triggers in patients with atopic eczema so patients can avoid these factors in the future.
- The panel recommends a therapeutic elimination diet following a diagnosis of food allergy or food-induced atopic eczema.
- The panel recommends against general dietary interventions for the treatment of atopic eczema.
In addition, several recommendations on incorporating the patient perspective in treatment decision making were provided:
- Providers should take a holistic approach to care rather than focusing on the skin alone.
- Providers should employ shared decision making in treatment planning.
- Comorbidities should be managed by multidisciplinary teams.
- Providers should be able to educate patients and caregivers about disease management.
Recommendations were also made for the management of atopic eczema during pregnancy, breastfeeding, and family planning:
- The panel recommends TCS class 2 or 3 in pregnant and breastfeeding women with atopic eczema.
- The use of TCS 2 or 3 or TCI is recommended in parents with atopic eczema who are planning to have a child.
- TCI is suggested to be used on the face and intertriginous areas as well as on the abdominal area, breast, and thigh skin where the risk of striae formation increases with TCS.
- In cases where topical treatments prove insufficient in pregnant women, the panel recommends narrow-band UVB or broad spectrum UVB therapy.
- Ciclosporin is suggested for pregnant women who are candidates for systemic therapy.
- The panel recommends against the use of long-term systemic corticosteroids in pregnant women.
- Prednisolone is suggested as only short-term rescue therapy for the management of acute flares in pregnant and breastfeeding women.
- The panel recommends against the use of abrocitinib, baricitinib, upadacitinib, methotrexate, and mycophenolate in pregnant women with atopic eczema.
- Methotrexate should be stopped 3 or more months before conception in individuals with atopic eczema who are planning to have a child.
Authors of the guideline wrote that the guideline was developed to provide an evidence-based, comprehensive update for atopic eczema care, particularly for practicing European clinicians. Despite this effort, the authors noted “that the guide- line document is already outdated regarding the fastest changing content, in particular the chapter on systemic therapy.”
Given the ongoing changes in the treatment landscape, the authors stated that they “plan to update the content of this aspect of the guideline on a regular basis, creating a ‘living’ guideline for systemic” treatments for atopic eczema.
Wollenberg A, Kinberger M, Arents B, et al. European guideline (EuroGuiDerm) on atopic eczema – part II: nonsystemic treatments and treatment recommendations for special AE patient populations. J Eur Acad Dermatol Venereol. 2022;36(11):1904-1926. doi:10.1111/jdv.18429