Translating Atopic Dermatitis Management Guidelines...

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Translating Atopic Dermatitis Management Guidelines Into Practice for Primary Care Providers Lawrence F. Eicheneld, MD a , Mark Boguniewicz, MD b , Eric L. Simpson, MD c , John J. Russell, MD d , Julie K. Block, BA e , Steven R. Feldman, MD, PhD f,g , Adele R. Clark, PA-C f , Susan Tofte, BSN, MS, FNP-C h , Jeffrey D. Dunn, PharmD, MBA i , Amy S. Paller, MD, MS j abstract Atopic dermatitis affects a substantial number of children, many of whom seek initial treatment from their pediatrician or other primary care provider. Approximately two-thirds of these patients have mild disease and can be adequately managed at the primary care level. However, recent treatment guidelines are written primarily for use by specialists and lack certain elements that would make them more useful to primary care providers. This article evaluates these recent treatment guidelines in terms of evaluation criteria, treatment recommendations, usability, accessibility, and applicability to nonspecialists and integrates them with clinical evidence to present a streamlined severity-based treatment model for the management of a majority of atopic dermatitis cases. Because each patients situation is unique, individualization of treatment plans is critical as is efcient communication and implementation of the plan with patients and caregivers. Specically, practical suggestions for individualizing, optimizing, implementing, and communicating treatment plans such as choosing a moisturizer formulation, avoiding common triggers, educating patients/ caregivers, providing written treatment plans, and scheduling physician follow-up are provided along with a discussion of available resources for patients/caregivers and providers. In 20092011, atopic dermatitis (AD) was estimated to affect 12.5% of children (017 years of age) in the United States, an increase of just over 5% since 19971999. 1 Among these patients, the vast majority (67%) are reported to have mild disease 2 and as such may be adequately managed by their pediatrician or other primary care provider (PCP). However, the majority of pediatricians refer even their mild patients to dermatologists (85%) and provide only initial, limited care (81%). 3 Whether or not patients are referred to dermatology, pediatricians and family practitioners continue to play a central role in patient management for regular follow-up, maintenance treatment, ongoing patient/caregiver education, and as the rst-line contact for ares and issues, such as secondary staphylococcal infection. On September 6, 2013, a roundtable was convened to discuss challenges in AD management along with opportunities to improve it across a variety of disciplines. This roundtable was unique in that it included a patient advocate, as well as representatives from dermatology (general and pediatric), pediatric allergyimmunology, family medicine, managed care, and nursing. During the discussion, it became clear that current AD management guidelines lack certain elements that may enhance their practical utility, especially for PCPs, a Departments of Pediatrics and Dermatology, School of Medicine, University of California, San Diego, San Diego, California; b Division of Pediatric Allergy-Immunology, Department of Pediatrics, National Jewish Health and School of Medicine, University of Colorado Denver, Colorado; c Departments of Dermatology, and h Nursing, Oregon Health & Science University, Portland, Oregon; d Department of Family and Community Medicine, Sydney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania; e National Eczema Association, San Rafael, California; f Department of Dermatology, g Pathology, and Public Health Sciences, Wake Forest Baptist Health, Winston-Salem, North Carolina; i VRx, Salt Lake City, Utah; and j Departments of Dermatology and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois Dr Eicheneld determined the agenda and faculty, served as co-chair, contributed substantially to the roundtable meeting, directed development of the manuscript text and graphical content, and critically reviewed each draft; Drs Boguniewicz, Simpson, Russell, Feldman, and Dunn, and Ms Block, Ms Clark, and Ms Tofte contributed substantially to the roundtable meeting and critically reviewed each draft of the manuscript; Dr Paller served as co-chair, contributed substantially to the roundtable meeting, directed development of the manuscript text and graphical content, and critically reviewed each draft; and all authors approved the nal manuscript as submitted. The content of this article is based on the proceedings of a roundtable meeting attended by each of the authors, held September 6, 2013, in Chicago, IL, and sponsored 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 STATE-OF-THE-ART REVIEW ARTICLE PEDIATRICS Volume 136, number 3, September 2015 by guest on September 8, 2018 www.aappublications.org/news Downloaded from
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  • 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

    abstract Atopic 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 patients 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 20092011, atopic dermatitis (AD)was estimated to affect 12.5% ofchildren (017 years of age) in theUnited States, an increase of just over5% since 19971999.1 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), pediatricallergyimmunology, 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

    STATE-OF-THE-ART REVIEW ARTICLE PEDIATRICS Volume 136, number 3, September 2015 by guest on September 8, 2018www.aappublications.org/newsDownloaded from

  • 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 meetings 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 Dermatologys(AAD) Guidelines4 and AmericanCollege of Allergy, Asthma, andImmunology (ACAAI)/AmericanAcademy of Allergy, Asthma, andImmunologys (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 AADGuidelines1013 (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 relapsingremitting 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 2014Guidelines1013 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, ClassIIIIV) 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

    sunsettedin

    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/immunologists

    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/immunologists

    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

    thepatientsguardian

    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)1013

    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, ClassIIIIV, see Table 3; except for face andeyes). Tacrolimus1821 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 VVII; 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, anddiaper 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), patients 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 IIIIV;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 hyperactivityimpulsivityand other mental health disorders.Positive associations between AD andattention-deficit/hyperactivitydisorder,2630 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 conditionsScabies Seborrheic dermatitis Photosensitivity dermatosesPsoriasis Contact dermatitis (irritant or allergic) Immune deficiency diseasesIchthyoses Cutaneous T-cell lymphoma Erythroderma of other causesAD, 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.2830 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,3234 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 chronicrelapsingremitting 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 betamethasone

    dipropionate0.05

    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

    IIIIV. 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 0.51

    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 patients 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 anadults index finger. This is equal to0.5 g and is an amount adequate forthin 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.

    PEDIATRICS Volume 136, number 3, September 2015 561 by guest on September 8, 2018www.aappublications.org/newsDownloaded from

  • 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 RadyChildrens 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 Childrens Hospital, 8010 Frost St, Suite 602, San Diego, CA 92123. E-mail:

    [email protected]

    562 EICHENFIELD et al by guest on September 8, 2018www.aappublications.org/newsDownloaded from

    http://nationaleczema.org/http://nationaleczema.orghttp://www.aafa.org/display.cfm?id=9&sub=23&cont=325http://www.aafa.org/display.cfm?id=9&sub=23&cont=325http://eczemacenter.orghttp://eczema.nm.orghttp://eczema.nm.orghttp://www.nationaljewish.org/programs/pediatric/atopic-dermatitishttp://www.nationaljewish.org/programs/pediatric/atopic-dermatitishttp://www.nationaljewish.org/programs/pediatric/atopic-dermatitishttp://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitishttp://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitishttp://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitishttp://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitishttp://www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/atopic-dermatitishttp://www.niams.nih.gov/Health_Info/Atopic_Dermatitishttp://www.niams.nih.gov/Health_Info/Atopic_Dermatitishttp://www.niams.nih.gov/Health_Info/Atopic_Dermatitismailto:[email protected]

  • 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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    MORE PERILS OFONLINEDATING:My friends range in age from their mid-20s tomid-70s. While many are in long-term committed relationships, quite a few arelooking for partners - either because they have yet to meet the right person, or arenowdivorced orwidowed. Almost all of those looking for a partner have used onlinedating services. My younger friends have grown up with these tools and are ap-propriately skepticalofwhatmaybeposted, butmyolder friendsandacquaintancesseem to be more accepting and trusting. Unfortunately that can be problematic.As reported in The New York Times (Your Money: July 17, 2015), criminals aretargeting somewhat older women (generally those in their 50s and 60s) on datingsites. Typically, the criminals hack into a dormant account and pose as someonefrom the United States who is now traveling overseas. The constant attention isinitially quite flattering and fills a void in the womans life. However, the swindlersoon begins to ask for money for various reasons ranging from hospitalization,identify theft, or business deals. The victimswind up sendingmoney and do not realizethe problem until huge sums have been lost. In Vermont, the victims on averagehave lost $40,000 to $100,000 dollars. One woman lost more than $200,000 dollars.The issue is such a problem that the Vermont State Legislature may pass a billrequiring online dating services to notify members of suspicious activity on theiraccounts. The AARP recommends that dating sites employ more sophisticatedalgorithms to detect suspicious patterns and that dating site members use searchengines to learn if the profile image they are viewing is used on multiple web siteswithdifferentnames.Regrettably,manyvictimsare soembarrassed that theydonotreport the losses to their family or friends. Recovering the money is extremelychallenging as these types of criminals use false email accounts andmanyare basedin West Africa. The best approach is to prevent such losses. While it should be self-apparent, one should be extremely cautious about sending money to someone youhave never actually met.

    Noted by WVR, MD

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  • DOI: 10.1542/peds.2014-3678 originally published online August 3, 2015; 2015;136;554Pediatrics

    S. PallerAmyK. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, Jeffrey D. Dunn and

    Lawrence F. Eichenfield, Mark Boguniewicz, Eric L. Simpson, John J. Russell, JuliePrimary Care Providers

    Translating Atopic Dermatitis Management Guidelines Into Practice for

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  • DOI: 10.1542/peds.2014-3678 originally published online August 3, 2015; 2015;136;554Pediatrics

    S. PallerAmyK. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, Jeffrey D. Dunn and

    Lawrence F. Eichenfield, Mark Boguniewicz, Eric L. Simpson, John J. Russell, JuliePrimary Care Providers

    Translating Atopic Dermatitis Management Guidelines Into Practice for

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