Translating Atopic DermatitisManagement Guidelines Into Practicefor Primary Care ProvidersLawrence F. Eichenfield, MDa, Mark Boguniewicz, MDb, Eric L. Simpson, MDc, John J. Russell, MDd, Julie K. Block, BAe,Steven R. Feldman, MD, PhDf,g, Adele R. Clark, PA-Cf, Susan Tofte, BSN, MS, FNP-Ch, Jeffrey D. Dunn, PharmD, MBAi,Amy S. Paller, MD, MSj

abstractAtopic dermatitis affects a substantial number of children, many of whom seekinitial treatment from their pediatrician or other primary care provider.Approximately two-thirds of these patients have mild disease and can beadequately managed at the primary care level. However, recent treatmentguidelines are written primarily for use by specialists and lack certainelements that would make them more useful to primary care providers. Thisarticle evaluates these recent treatment guidelines in terms of evaluationcriteria, treatment recommendations, usability, accessibility, and applicabilityto nonspecialists and integrates them with clinical evidence to presenta streamlined severity-based treatment model for the management ofa majority of atopic dermatitis cases. Because each patient’s situation isunique, individualization of treatment plans is critical as is efficientcommunication and implementation of the plan with patients and caregivers.Specifically, practical suggestions for individualizing, optimizing,implementing, and communicating treatment plans such as choosinga moisturizer formulation, avoiding common triggers, educating patients/caregivers, providing written treatment plans, and scheduling physicianfollow-up are provided along with a discussion of available resources forpatients/caregivers and providers.

In 2009–2011, atopic dermatitis (AD)was estimated to affect 12.5% ofchildren (0–17 years of age) in theUnited States, an increase of just over5% since 1997–1999.1 Among thesepatients, the vast majority (∼67%) arereported to have mild disease2 and assuch may be adequately managed bytheir pediatrician or other primary careprovider (PCP). However, the majorityof pediatricians refer even their mildpatients to dermatologists (∼85%) andprovide only initial, limited care(81%).3 Whether or not patients arereferred to dermatology, pediatriciansand family practitioners continue toplay a central role in patientmanagement for regular follow-up,maintenance treatment, ongoing

patient/caregiver education, and as thefirst-line contact for flares and issues,such as secondary staphylococcalinfection.

On September 6, 2013, a roundtablewas convened to discuss challenges inAD management along withopportunities to improve it acrossa variety of disciplines. This roundtablewas unique in that it included a patientadvocate, as well as representativesfrom dermatology (general andpediatric), pediatricallergy–immunology, family medicine,managed care, and nursing. During thediscussion, it became clear that currentAD management guidelines lack certainelements that may enhance theirpractical utility, especially for PCPs,

aDepartments of Pediatrics and Dermatology, School ofMedicine, University of California, San Diego, San Diego,California; bDivision of Pediatric Allergy-Immunology,Department of Pediatrics, National Jewish Health and School ofMedicine, University of Colorado Denver, Colorado;cDepartments of Dermatology, and hNursing, Oregon Health &Science University, Portland, Oregon; dDepartment of Familyand Community Medicine, Sydney Kimmel Medical College,Thomas Jefferson University, Philadelphia, Pennsylvania;eNational Eczema Association, San Rafael, California;fDepartment of Dermatology, gPathology, and Public HealthSciences, Wake Forest Baptist Health, Winston-Salem, NorthCarolina; iVRx, Salt Lake City, Utah; and jDepartments ofDermatology and Pediatrics, Feinberg School of Medicine,Northwestern University, Chicago, Illinois

Dr Eichenfield determined the agenda and faculty, servedas co-chair, contributed substantially to the roundtablemeeting, directed development of the manuscript text andgraphical content, and critically reviewed each draft;Drs Boguniewicz, Simpson, Russell, Feldman, and Dunn,and Ms Block, Ms Clark, and Ms Tofte contributedsubstantially to the roundtable meeting and criticallyreviewed each draft of the manuscript; Dr Paller servedas co-chair, contributed substantially to the roundtablemeeting, directed development of the manuscript text andgraphical content, and critically reviewed each draft; andall authors approved the final manuscript as submitted.

The content of this article is based on the proceedingsof a roundtable meeting attended by each of theauthors, held September 6, 2013, in Chicago, IL, andsponsored by Valeant Pharmaceuticals North America,LLC (Bridgewater, NJ).

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3678

DOI: 10.1542/peds.2014-3678

Accepted for publication Feb 26, 2015

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including pediatricians. This articlewill (1) evaluate the utility of currentguidelines, (2) present an integrated,PCP-specific treatment model basedon current guidelines and clinicalevidence, (3) give practical advice onthe implementation and optimizationof written, individualized treatmentplans for patients, and (4) providerecommendations to improve theutility of future guidelines, all basedon the meeting’s proceedings.

RECENT AD MANAGEMENT GUIDELINES

To improve utility, managementguidelines should contain a concisetreatment algorithm that is severity-based and not rigid (ie, allows forunique patient situations) withinstructions for when to step-up orstep-down treatment. Diagnostic andseverity evaluation criteria should beincluded to provide a framework forinitial and ongoing evaluation. Also,guidelines should reflectmultidisciplinary input and be freelyand easily accessible to all health careproviders (HCPs), regardless ofspecialty.

With each iteration, AD managementguidelines have improved accordingto these fundamentals from the 2004American Academy of Dermatology’s(AAD) Guidelines4 and AmericanCollege of Allergy, Asthma, andImmunology (ACAAI)/AmericanAcademy of Allergy, Asthma, andImmunology’s (AAAAI) PracticeParameters5 through the 2006European Academy of Allergologyand Clinical Immunology (EAACI)/AAAAI Guidelines6 to the current2012 European Dermatology Forum(EDF) Guidelines,7,8 2012 AAAAI/ACAAI Practice Parameter Update(published in 2013),9 and 2014 AADGuidelines10–13 (Table 1). Ofparticular note, the 2012 AAAAI/ACAAI Practice Parameter and EDFGuidelines include input from HCPsfrom both allergy/immunology anddermatology and specify that theirrecommendations may be useful toHCPs outside of those therapeutic

areas. The 2012 EDF Guidelines areunique in providingrecommendations for monthlyamounts of topical corticosteroids toprescribe and how to quantify dailyamounts of topical drug for patients.

Integrating Guidelines With ClinicalEvidence

With so many AD managementguidelines promulgated by differentgroups, there is potential for these toconflict with each other, making itdifficult for HCPs to determine whichguidelines are best suited for theirpatients. The consensus amongroundtable participants was thatPCPs could benefit from an integratedplan that is more straightforward andspecific, accommodates the majorityof the cases they encounter, andprovides guidance as to when to referto a dermatologist or allergist/immunologist. In addition, fewguidelines contain a treatment modeland, those that do, fail to account forthe relapsing–remitting nature of ADor for the use of proactivemanagement.

To address these gaps and providea useful tool for pediatricians andPCPs in managing their patients withAD, we propose the followingdiagnostic and treatment modelbased on the EDF 2012 Guidelines,7,8

the ACAAI and AAAAI 2012 PracticeParameters,9 and the AAD 2014Guidelines10–13 with publishedclinical evidence as support (Fig 1).

Making the Diagnosis

Because there is no definitivelaboratory test, a diagnosis of AD ismade based on a combination ofclinical symptoms: pruritic dermatitisthat is chronic and/or relapsing withcharacteristic distribution (face, neck,and extensor surfaces in infants andchildren; flexural folds in patients ofany age). Diagnosis is often madeduring an acute exacerbation of skininflammation characterized byintensely pruritic, erythematouspapules and patches accompanied bydry skin (ie, xerosis), excoriations,

and sometimes serous exudate. Thediagnostic criteria given in the AADguidelines (Table 2)14 provide a user-friendly set of criteria that mirrormany more lengthy validated criteria.A diagnosis of AD should only bemade when other conditions havebeen ruled out such as irritantcontact dermatitis, psoriasis, scabies,or a viral exanthem. A variety ofscoring systems have been proposedfor quantifying AD severity. Milddisease generally involves less bodysurface area, has a more remittivecourse, and is associated with lowerintensity itch.15 Patients who can bemaintained with basic managementalone most often have mild disease.Patients with moderate-to-severedisease may have greater bodysurface area involvement with morecontinuous course and more severeitch.15 These patients often requiremore maintenance therapy.

Basic Management

Regardless of disease severity, basicmanagement strategies should beimplemented for every patientdiagnosed with AD (Fig 1). Theseinclude proper skin care (ie, skinhydration and moisturizer applied toall skin), antiseptic measures(ie, dilute bleach baths), and triggeravoidance (general avoidance ofirritants as identified for eachpatient), with acute treatment addedas needed for flares (ie, acuteescalation in symptoms and skininflammation necessitating anescalation in treatment and/ormedical advice16).

Acute Treatment of Flares

Depending on patient and providerpreference, treatment of acute flaresmay be managed with topicalcorticosteroids of varying potency(Table 3),17 and medium potencytopical corticosteroids (eg, ClassIII–IV) are often used for several daysto a few weeks.11 Subsequentmaintenance therapy then dependson the severity, as well as persistenceof AD signs and symptoms.

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TABLE1

Recent

ADManagem

entGuidelines

Methodology

(Sponsoring

Organization[s],Year)

EvaluationCriteria

Treatm

entRecommendations

Utility

Diagnostic

Criteria?

Severity

Evaluation?

Algorithm?

Severity-Based?

Criteriato

Step-Up/

DownTreatm

ent?

Usability

Applicability:W

orking

Group

Compositionand/or

Intended

Audience

Accessibility

Composite

ofevidence

with

references

for9AD

managem

entquestions

(AAD,2004)4

NoNo

NoNo

NoTreatm

entrecommendations

listedonlyin

text

Free

from

AAD,

but

notfrom

journal

Levelof

evidence

and

consensusof

opinionlisted

separatelyfrom

recommendations

Guidelines

“sunsetted”in

2009,

butn

onewguidelines

issued

until

2014

Working

groupincluded

only

derm

atologists

Review

ofliteraturerated

bycategory

ofevidence

andstrength

ofrecommendation(ACAAI

andAAAAI,2004)5

Yes

Onlyfor

severe

Annotatedlinear

managem

ent

andtreatm

ent

model

Yes

Yes

Treatm

entrecommendations

(with

strength

ofrecommendation)

and

algorithm

details

onlylisted

intext

“The

evaluationandmanagem

ent

ofAD

are…

anintegral

part

ofan

allergist/immunologist’s

training

andpractice.Itisalso

importantforthePCPto

understand

thebasisfor

effectiveevaluationand

managem

ent…

”

Free

from

AAAAI

andJTFbutnot

from

journal

Annotations

andsummary

statem

ents

notintegrated

with

algorithm

Review

ofliterature(EAACI

andAAAAI/P

RACTALL,

2006)6

Yes

NoStepwise

treatm

ent

model

Yes(but

severity

criterianot

included)

No(and

nocriteria

forwhento

use

topical

corticosteroids

6TCI)

Treatm

entanddiagnosis

recommendations

listedonly

intext

Working

groupincluded

allergists/immunologists

and

derm

atologists

Free

from

1of

2journals

Nolevelof

evidence

indicated

Compilationof

existing

European

evidence-

basedguidelines

supplementedwith

new

literatureratedby

grade

ofevidence

andstrength

ofrecommendation(EDF,

2012)7,8

Committee

decidedthat

guidelines

should

strictly

concentrateon

therapeutic

regimensand

omitsections

onclinical

diagnosis

NoYes

Yes

Treatm

entrecommendations

(with

levelof

evidence

and

strength

ofrecommendation)

onlylisted

intext

“Thisguidelinehasbeen

prepared

forphysicians,

especiallyderm

atologists,

pediatricians,general

practitioners

andall

specialists

taking

care

ofpatientssuffering

from

[AD]”

Free

from

EDFand

GAAPP,butnot

from

journal

Provides

guidance

formonthly

amountsof

topical

corticosteroids(ingram

s)andhowto

quantifytopical

therapyam

ounts(ie,FTU)

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TABLE1

Continued

Methodology

(Sponsoring

Organization[s],Year)

EvaluationCriteria

Treatm

entRecommendations

Utility

Diagnostic

Criteria?

Severity

Evaluation?

Algorithm?

Severity-Based?

Criteriato

Step-Up/

DownTreatm

ent?

Usability

Applicability:W

orking

Group

Compositionand/or

Intended

Audience

Accessibility

Review

ofliteraturerated

bycategory

ofevidence

andstrength

ofrecommendation

(updateof

ACAAIand

AAAAI2004Practice

Parameter,2012)9

Yes

Onlyfor

severe

Annotatedlinear

managem

ent

andtreatm

ent

model

Yes

Yes

Treatm

entrecommendations

(with

strength

ofrecommendation)

and

algorithm

details

onlylisted

intextas

part

ofonline

supplement

“The

evaluationandmanagem

ent

ofAD

arean

integralpartofan

allergist/immunologist’s

training

andpractice.Itisalso

importantforthePCPto

understand

thebasisfor

effectiveevaluationand

managem

ent…

”

Free

from

AAAAI,

JTF,andjournal

(including

online

supplement)

Algorithm

annotations

and

summarystatem

ents

not

integrated

with

algorithm

“Cooperationbetweenthepatient

and/or

thepatient’sguardian

orguardians,thePCP,andthe

allergist,derm

atologist,or

both

isimportantin

the

implem

entationof

strategies

necessaryforthecare

ofpatientswith

chronicAD…

Even

whenan

ADspecialistis

consulted,thePCPcontinues

toplay

animportantrole

inthecare

ofpatientswith

ADby

ensuring

continuityof

care.”

Inadditionto

allergists/

immunologists,taskforce

included

psychologist

and

derm

atologists

Recommendations

ratedby

gradeof

evidence

and

strength

ofrecommendationwith

references

for17

ADdiagnosisand

managem

entquestions

(updateofAAD2004,AAD

Guidelines,2014)10–13

Yes

NoNo

NoNo

Treatm

entanddiagnosis

recommendations

listedin

tables

Inadditionto

derm

atologists,

working

groupincluded

patient

advocate

and

internationalrepresentatives

(CanadaandUK)

Free

from

AAD,

but

notfrom

journal

Levelof

evidence

andstrength

ofrecommendationlisted

separatelyfrom

recommendations

Clinical

questions

that

arenew

sincelastissuance

indicated

AAAAIindicates

American

Academ

yofAllergy,AsthmaandImmunology;AAD,Am

erican

Academ

yofDerm

atology;ACAAI,Am

erican

College

ofAllergy,AsthmaandImmunology;AD,atopicderm

atitis;EAACIEuropeanAcadem

yofAllergologyandClinical

Immunology;EDF,European

Derm

atologyForum;FTU,fingertip

unit;GAAPP,GlobalAllergyandAsthmaPatient

Platform

;HCP,healthcare

provider;JTF,AAAAI/ACAAIJointTaskForceon

PracticeParameters;PRACTALL,PracticalAllergy;PCP,primarycare

physician;

TCI,topicalcalcineurininhibitor.

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Maintenance Therapy for Mild Disease

After the initial flare has beencontrolled, many patients with mildor more episodic AD will be able tomaintain disease control with basictreatment as described above:moisturizers, proper skin care, etc,intermittently returning to acutetopical corticosteroid treatment asneeded for flares. The use ofmoisturizers alone as maintenancetherapy, without a topicalantiinflammatory, is usually sufficientfor mild AD. Patients whosesymptoms are not well controlledwith basic treatment are consideredto have moderate-to-severe disease.

Maintenance Therapy for Moderate-to-Severe Disease

Patients with moderate-to-severe ADmay require “proactive”/maintenancetherapy regularly applied to normalappearing skin in flare-prone areasand/or applied at first signs orsymptoms of a flare with tacrolimus

or pimecrolimus (topical calcineurininhibitors [TCIs]) or medium potencytopical corticosteroids (eg, ClassIII–IV, see Table 3; except for face andeyes). Tacrolimus18–21 andfluticasone22 have each been studiedin long-term clinical trials of 2- to3-times weekly application.Alternatively, a patient may beprescribed once to twice daily TCI(pimecrolimus or tacrolimus); clinicaltrials of this scenario have also beenconducted.23,24 Although it has notbeen studied, low potency topicalcorticosteroids (Class V–VII; seeTable 3), applied locally once to twicedaily to areas prone to recurrence, isused by many patients to maintaindisease control. The choice of TCIversus topical corticosteroids formaintenance therapy depends onpatient/caregiver and providerpreference, access to medications(including formulary status and costof medication), lesion location(topical corticosteroid use in sensitive

skin areas such as the face and eyesshould be limited), and theeffectiveness and tolerabilityobserved with a particular agent.Furthermore, for long-term use, it isimportant to use the lowest potencytopical corticosteroid that is effectiveto minimize the risk of adverse effects(skin atrophy, telangiectasia, striae,glaucoma, rebound flare, topicalcorticosteroid addiction/withdrawal,tachyphylaxis, Cushing disease,adrenocortical suppression,decreased growth rate25); this isparticularly true for sensitive skinsites, such as the face, neck, and“diaper area.”11 Failure to adequatelysuppress skin inflammation not onlyperpetuates discomfort but also leadsto continued scratching and anincreased risk for infection.

Optimizing and IndividualizingTreatment Plans

When designing a treatment plan fora specific patient, a provider should

FIGURE 1Proposed treatment model/eczema action plan for pediatricians and other primary care providers. aAs tolerated during flare; direct use of moisturizerson inflamed skin may be poorly tolerated; however, bland petrolatum is often tolerated when skin is inflamed. bApproximately 0.5 cups sodiumhypochlorite per 40 gallons of water/full bathtub or 1 mL/L. TCI, topical calcineurin inhibitor

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tailor it based on patient age,previous treatment failures, who isproviding care (for children/infants),lesion location (topical corticosteroiduse must be limited in potency andduration of application for sensitiveskin areas), patient’s insurance andfinancial resources to getmedications, patient/family lifestyle(ie, time for baths and moisturizer/topical antiinflammatory application),and patient preferences (look/feel ofointments versus creams). Patient/caregiver preferences are especiallyimportant when selectinga moisturizer formulation becausexerosis is the central feature of AD.Lotions contain preservatives,fragrances, and other chemicals,which may cause allergic or irritantreactions. Lotions have a high watercontent and, especially for moreseverely xerotic patients, may bedrying; moisturizer ointments withhigher oil content and nopreservatives may be preferable.9,11

The choice of moisturizer should bebased on patient preference/tolerance for the occlusiveness ofointments and oils versus creams orlotions. Similar considerations shouldbe made for patient/caregiver

preferences for formulation of topicalantiinflammatories, as well asconsideration for the cost ofmedication. It should be noted thatdifferent formulations of the sametopical corticosteroid, even the sameconcentration of topicalcorticosteroid, may have differentpotencies, for example mometasonefuroate 0.1% ointment is highpotency (Class II), whereasmometasone furoate 0.1% cream ismedium potency (Class III–IV;Table 3).

Determination of patient-specific ADtriggers is challenging, but if thesetriggers can be identified, avoidancemay lead to longer intervals betweenflares and even complete diseaseclearance in some cases. Nonspecifictriggers may include harsh soaps,detergents, wool, and other abrasivefabrics, tight-fitting clothing, certainchemicals (eg, formaldehyde used forfabric sizing), airborne irritants(tobacco smoke, air pollution), andextremes or transitions intemperature and humidity. Rarely,allergies can be triggers of dermatitis,and food and environmental allergiesare more common in children withAD than in those without.13

Sensitization for food andenvironmental allergens can beidentified by using skin prick orspecific IgE tests, and contact allergymay be assessed through patchtesting. However, providers shouldnot suggest routine testing in thesearch for “causes” of AD, because thepredictive value of positive tests islow, and often true clinical allergiesmay be irrelevant as AD triggers (eg,may cause a reaction such asurticaria, or itch, without necessarilyflaring AD).9,13 “Relevant” allergensdiffer by age group: young childrenare more likely to have food allergy(although the minority of infants andchildren who show reactivity throughprick or blood testing have trueclinical allergy), whereas olderchildren and adults are more likely tohave sensitivity to aeroallergens.9,13

Many patients experience sleepdisturbance, especially during flares,which not only negatively affectsquality of life, but may also increasethe risk of hyperactivity–impulsivityand other mental health disorders.Positive associations between AD andattention-deficit/hyperactivitydisorder,26–30 anxiety disorders,26,30

depression,30 and autism spectrum

TABLE 2 Diagnostic Criteria

Essential Features Important Features Associated Features

Both must be present Add support to the diagnosis, observed in mostcases of AD

Suggestive of AD, but too nonspecific to be used fordefining or detecting AD in research or epidemiologicstudies

1. Pruritus 1. Early age of onset 1. Atypical vascular responses (eg, facial pallor, whitedermographism, delayed blanch response)

2. Eczema (acute, subacute, chronic) 2. Atopy 2. Keratosis pilaris/pityriasis alba/hyperlinear palms/ichthyosis

a. Typical morphology and age-specificpatterns

a. Personal and/or family history 3. Ocular/periorbital changes

•Infants/children: facial, neck, andextensor involvement

b. IgE reactivity4. Other regional findings (eg, perioral changes/periauricular lesions)

•Any age group: current or previousflexural lesions

3. Xerosis5. Perifollicular accentuation/lichenification/prurigolesions

•Sparing of the groin and axillary regionsb. Chronic or relapsing history

Exclusionary Conditions

Diagnosis of AD depends on excluding conditions•Scabies •Seborrheic dermatitis •Photosensitivity dermatoses•Psoriasis •Contact dermatitis (irritant or allergic) •Immune deficiency diseases•Ichthyoses •Cutaneous T-cell lymphoma •Erythroderma of other causes

AD, atopic dermatitis; IgE, immunoglobulin E. Adapted from Eichenfield et al.14

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disorders30 have been reported,especially among patients with ADand sleep loss.28–30 In patients whohave a major complaint of sleep lossor who have risk factors for 1 or moreof these mental health comorbidities,antihistamines (hydroxyzine ordoxepin),31 topicalantiinflammatories,32–34 emollients,35

hypnotherapy,36 and/or reducingsensory input37 may be beneficial.

Finally, all treatment plans shouldinclude scheduled follow-up(telephone call, office visit, etc),optimally within 1 to 2 weeks afterthe initial visit, to assess treatment

adherence and patient/caregiversatisfaction and comfort level withthe plan. Early follow-up may lead tobetter adherence and bettertreatment outcomes.

TREATMENT PLAN IMPLEMENTATIONAND COMMUNICATION WITH PATIENTSAND CAREGIVERS

Written Treatment Plan

Incorporating instructions intoa written plan (similar to what iscommonly implemented for asthmapatients) regarding when to applymoisturizers and topical medications,

when to step-up or step-downtreatment, when to seek medicaladvice, what triggers to avoid, etc, iscritical to ensuring good long-termtreatment adherence. The currentconversion to electronic medicalrecords presents an opportunity toautomate plan creation. In addition,treatment plan handouts are freelyavailable for duplication anddistribution to patients and/orcaregivers.38

Patient and Caregiver Education

It is important for patients,caregivers, and family members tounderstand the chronicrelapsing–remitting nature of AD andhow the implementation of a writtentreatment plan, including proper skincare, antiseptic measures, triggeravoidance, and pharmacologictreatment, can help to extend periodsof remission. The process of patient/caregiver education should start withthe initial plan development andcontinue through each follow-up visit(especially when the treatment planhas been modified) with thephysician, nurse, or other medicalstaff to ensure that the currenttreatment plan is well understood.Additionally, time spent on educationaffords the physician (or other HCP)the opportunity to correct anymisconceptions patients and/orcaregivers may have and toproactively address any potentialinsurance or dispensing issues, ifrequired.

Patients/caregivers should beinstructed on proper skin care,including skin hydration with warmsoaking baths or showers,immediately followed by applicationto damp skin of an adequate amountof moisturizer (Fig 2).8,9,11 Inaddition, adding a small amount ofbleach (sodium hypochlorite; ∼0.5cups per 40 gallons of water/fullbathtub or 1 mL/L) on a twice weeklybasis has been shown to reduce ADseverity.39 Daily use of these dilutebleach baths, or comparable sodiumhypochlorite-based products while

TABLE 3 Topical Corticosteroid Potencies, Strengths, and Formulations

Class Strength, % Available Formulations

Drug Ointment Cream Lotion Foam Solution Gel

I. Very high potencyAugmented betamethasone

dipropionate0.05 ✓

Clobetasol propionate 0.05 ✓ ✓ ✓ ✓

Diflorasone diacetate 0.05 ✓

Halobetasol propionate 0.05 ✓ ✓

II. High potencyAmcinonide 0.1 ✓ ✓ ✓

Augmented betamethasonedipropionate

0.05 ✓

Betamethasone dipropionate 0.05 ✓ ✓ ✓ ✓

Desoximetasone 0.25 0.25 0.05Diflorasone diacetate 0.05 ✓

Fluocinonide 0.05 ✓ ✓ ✓ ✓

Halcinonide 0.1 ✓ ✓

Mometasone furoate 0.1 ✓

Triamcinolone acetonide 0.5 ✓ ✓

III–IV. Medium potencyBetamethasone valerate 0.1 ✓ ✓ ✓ ✓

Clocortolone pivalate 0.1 ✓

Desoximetasone 0.05 ✓

Fluocinolone acetonide 0.025 ✓ ✓

Flurandrenolide 0.05 ✓ ✓

Fluticasone propionate 0.005 0.05Mometasone furoate 0.1 ✓

Triamcinolone acetonide 0.1 ✓ ✓

V. Lower-medium potencyHydrocortisone butyrate 0.1 ✓ ✓ ✓

Hydrocortisone probutate 0.1 ✓

Hydrocortisone valerate 0.2 ✓ ✓

Prednicarbate 0.1 ✓

VI. Low potencyAlclometasone dipropionate 0.05 ✓ ✓

Desonide 0.05 ✓ ✓ ✓ ✓

Fluocinolone acetonide 0.01 ✓ ✓

VII. Lowest potencyDexamethasone 0.1 ✓

Hydrocortisone 0.25, 0.5, 1 ✓ ✓ ✓ ✓

Hydrocortisone acetate 0.5–1 ✓ ✓

Includes representative examples and not all available agents. Adapted from Paller and Mancini.18

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showering or otherwise washing,40

may be needed as part ofmaintenance therapy for moderate toseverely affected children (althoughthe effect of managing bacterialcolonization alone on recurrentinfection has not been established41).The technique can be modified formore local soaking or compressingfor maintenance of areas that moreoften show secondary infection or forpatients with current infection whocannot tolerate bathing. Proper skincare will also help reduce exposureand/or impact of certain AD triggersby increasing the patient’s thresholdfor skin irritation.

Wet-wrap therapy (WWT; with orwithout topical corticosteroids) mayreduce disease severity, especially forpatients with moderate-to-severe ADduring flares11; however, WWT canbe time-consuming and complicated.Patients/caregivers should beinstructed in the application of loose,wetted (soaked in warm water, thenwrung out until slightly damp)tubular bandages, gauze, or cottonclothing over topical corticosteroid ormoisturizer, followed by a dry outerlayer of similar material (neverplastic wrap), which may be worn forseveral hours to 24 hours andrepeated for several days to 2weeks.42 Care should be taken duringWWT, especially when usingmedium-to-high potency topicalcorticosteroids, due to increased risk

of topical corticosteroid penetrationand infection. For complete step-by-step directions, see Nicol et al.43

Patients/caregivers should beadvised to avoid nonspecific irritantsby using mild soaps or soap-freecleansers, wearing “smooth”/nonirritating clothing that is loose-fitting, and avoiding detergents andfabric softeners with fragrances.9,13

In addition, exposure to aeroallergens(molds, dust mites, pollen, animaldander, airborne irritants), andextremes in temperature andhumidity may be avoided, orminimized through the use of airconditioning and/or air filters.9

Patients/caregivers should also beinstructed on avoidance strategies forAD triggers specific to them (ie, foods,contact and aero-allergens) asdetermined through planoptimization and individualization(above).

It is also critically important toinstruct patients/caregivers on thequantity of topical medication andmoisturizer to use for eachapplication and the total quantityexpected to be consumed per week ormonth (Fig 2). The fingertip unit(FTU) has been developed asa helpful tool for quantitativelydescribing for patients/caregivers theamount of topical medication to beused.44,45 It is defined as the amountof ointment expressed from a tubewith a 5-mm diameter nozzle

measured from the distal skin creaseto the tip of the palmar surface of anadult’s index finger. This is equal to∼0.5 g and is an amount adequate for“thin and even” application to an areaof skin equal to ∼2 adult hands withfingers together. The number of FTUsrequired to treat different body areasvaries with patient age, but FTUs aremeasured relative to adult hands/fingers regardless of age (Fig 2).Providers may also find it helpful toprescribe specific amounts ofa topical agent to be used over thecourse of 1 week or month to ensureproper use of topical corticosteroids,TCIs, and/or moisturizer (Fig 2).Asking patients/caregivers to bringtheir partially used bottles/tubes intothe office during their next visit maybe helpful in assessing adherence(although the possibility ofmedication “dumping” should be keptin mind). Despite proper instruction,some patients/caregivers may stillnot apply adequate amounts oftopical corticosteroids because ofa fear of side effects (ie, “steroidphobia”). Making patients/caregiversaware of the signs of skin atrophy (eg,increased transparency and shininessof the skin; striae) and explaining thatmild cutaneous side effects arereversible with time (but striae arenot) may allay some of these fearsand increase adherence.

Written plans and patient/caregivereducation have the potential to

FIGURE 2Topical application amounts. aMeasurements/quantities are relative to adult hand/finger sizes, regardless of age group. bQuantity for creams should beincreased by ~10% over ointment.30 cQuantity for moisturizers may exceed the suggested values. dEstimated based on monthly amounts for 2 to 3 timesweekly application per Ring et al.7 FTU, fingertip unit.

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improve treatment adherence, whichis a major determinant of treatmentsuccess. There are a number ofadditional strategies pediatriciansand PCPs can use to improveadherence among their patients,including engaging patient andcaregivers in discussions aboutprevious medications/experiences,suggesting support from groups suchas the National Eczema Association(NEA; http://nationaleczema.org/),addressing side effects proactively,positive reinforcement, frequentfollow-up visits, accessing managedcare compliance and caremanagement programs, and, in themost noncompliant patients, applyingmedications in the office. Stickercharts may be a particularly usefultool for improving adherence amongpediatric patients.46 Many patients/caregivers may wish to discusscomplementary and alternativetherapies; these should be reviewedin an open-minded way, although atthis time there is limited clinical datasupporting their use.13 Considerationof referral to a child psychologist isappropriate in cases wherebehavioral support beyond patientand caregiver education is needed.The NEA is a valuable resource forpatient/caregiver education andsupport. Educational brochures areavailable for distribution byproviders. Regarding skin careproducts, NEA maintains a list thathave satisfied the NEA Seal ofAcceptance criteria for sensitivity,safety, and toxicity, as well asingredients, content, and formulation.In addition, providers may find ithelpful to form cooperative groups ofHCPs within their practice or localarea to facilitate coordination of care,information sharing, and pooling ofresources.

Patients/caregivers as well aspediatricians and other PCPs may

find the following Web sites to behelpful resources:

• NEA: http://nationaleczema.org

• AD information from the Asthmaand Allergy Foundation of America:http://www.aafa.org/display.cfm?id=9&sub=23&cont=325

• The Eczema Center at RadyChildren’s Hospital San Diego:http://eczemacenter.org

• Northwestern MultidisciplinaryEczema Center: http://eczema.nm.org

• The Pediatric Atopic DermatitisProgram at National Jewish Health:http://www.nationaljewish.org/programs/pediatric/atopic-dermatitis

• AD information from the AAD:http://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitis

• AD information from the NationalInstitute of Arthritis and Musculo-skeletal and Skin Diseases: http://www.niams.nih.gov/Health_Info/Atopic_Dermatitis

CONCLUSIONS

Pediatricians and other PCPs playa central role in the management ofAD, be it by referring patients withmoderate-to-severe AD forspecialized care, providing ongoingmaintenance care after evaluation byspecialists, or managing patients withmild or more episodic AD themselves.The treatment model proposed in thisarticle is designed specifically for useby pediatricians and other PCPs andincludes basic management measures(skin care, antiseptic measures, andtrigger avoidance) to be usedregardless of AD severity, acutetreatment of flares with low ormedium potency topicalcorticosteroids depending on severityof the flare, and maintenance

treatment with TCI and/or topicalcorticosteroids for patients withmoderate-to-severe disease. Becausethe course of AD varies from patientto patient, it is critical to designtreatment plans based on patients’/caregivers’ individual preferences andneeds including patient age, familylifestyle, preference for topicaltreatment formulation, and pattern oflesions and flares. Patient andcaregiver education should includea written treatment plan andinstruction on trigger avoidance andcorrect topical treatment application.Treatment plans should becontinually optimized and refinedduring regular follow-ups.

ACKNOWLEDGMENTS

All roundtable and article contentwas developed independent offunding source. Jennifer Jaworski, MS,a full-time employee of PrescottMedical Communications Group(Chicago, IL) assisted withpreparation of the article at thedirection of the authors with financialsupport from Valeant.

ABBREVIATIONS

AAAAI: American Academy ofAllergy, Asthma andImmunology

AAD: American Academy ofDermatology

ACAAI: American College ofAllergy, Asthma andImmunology AD: atopicdermatitis

EDF: European DermatologyForum

FTU: fingertip unitHCP: healthcare providerNEA: National Eczema AssociationPCP: primary care providerTCI: topical calcineurin inhibitorWWT: wet-wrap therapy

Address correspondence to Lawrence F. Eichenfield, MD, Pediatric Dermatology, Rady Children’s Hospital, 8010 Frost St, Suite 602, San Diego, CA 92123. E-mail:

leichenfield@rchsd.org

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: Funded by Valeant Pharmaceuticals North America, LLC.

POTENTIAL CONFLICT OF INTEREST: Dr Eichenfield has been a principal investigator for Astellas Pharma US, Inc, Galderma Laboratories, LP, and Stiefel Laboratories,

Inc; he has received compensation for his work as a consultant for Valeant Pharmaceuticals North America, LLC, Anacor Pharmaceuticals, Inc, Galderma, Promius

Pharma, LLC, and Stiefel, TopMD, Inc; Drs Boguniewicz and Simpson have received financial compensation for their work as consultants for Valeant Pharmaceuticals

North America, LLC; Dr Russell has received financial compensation for his work as a consultant for Valeant Pharmaceuticals North America, LLC, as a Speakers

Bureau member for SanofiPasteur US, and as an Advisory Board member for Takeda Pharmaceuticals USA, Inc; Ms Block is a salaried executive of National Eczema

Association, which has received grants and sponsorship awards from a variety of industry partners including Valeant Pharmaceuticals North America, LLC (full list

at: http://nationaleczema.org/corporate-partners/); Dr Feldman has received research, speaking and/or consulting support from a variety of companies including

Valeant Pharmaceuticals North America, LLC, Astellas Pharma US, Inc, AbbVie, Inc, Advance Medical, Amgen, Inc, Anacor Pharmaceuticals, Inc, Baxter, Boehringer

Ingelheim GmbH, CVS/caremark, Celgene Corporation, Eli Lilly and Company, Galderma Laboratories, LP, Informa Healthcare, Janssen Pharmaceutical, Inc, Leo

Pharma, Inc, Pfizer, Inc, Merck & Co, Inc, Merz Pharma GmbH & Co KGaA, Mylan, Inc, National Biological Corp, Novartis Corporation, Qurient Co, Ltd, Stiefel

Laboratories, Inc, Suncare Research Laboratories, LLC, UpToDate, Inc, and National Psoriasis Foundation, and Dr Feldman is founder and part owner of Causa

Research, a company dedicated to enhancing patients’ adherence to treatment; Ms Clark has been a subinvestigator for Astellas Pharma US, Inc, Medicis

Pharmaceutical Corporation (now part of Valeant), Galderma Laboratories, LP, Anacor Pharmaceuticals, Inc, Stiefel Laboratories, Inc, Maruho Co, Ltd, Merz Pharma

GmbH & Co KGaA, Regeneron Pharmaceuticals, Inc, and HanAll Biopharma, and she has received financial compensation for her work as a consultant for Valeant

Pharmaceuticals North America, LLC; Ms Tofte has received financial compensation for her work as a consultant for Valeant Pharmaceuticals North America, LLC,

and as Advisory Board member for Amgen, Inc, and Johnson & Johnson Consumer & Personal Products Worldwide; Dr Dunn has received financial compensation

for his work as a consultant for Valeant Pharmaceuticals North America, LLC, and Stiefel Laboratories, Inc; Dr Paller has been a principal investigator for Anacor

Pharmaceuticals, Inc, Astellas Pharma US, Inc, and TopMD, Inc, and she has received financial compensation for her work as a consultant for Valeant

Pharmaceuticals North America, LLC, Anacor, Galderma Laboratories, LP, Onset Dermatologics, Promius Pharma, LLC, and Stiefel Laboratories, Inc.

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AmyK. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, Jeffrey D. Dunn and Lawrence F. Eichenfield, Mark Boguniewicz, Eric L. Simpson, John J. Russell, Julie

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