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New Recommendations Issued for Severe AD

Current national and international guidelines differ on the management of severe atopic dermatitis (AD). In a recent clinical management review, researchers created a comprehensive set of recommendations for the management of patients with severe atopic dermatitis (AD). These recommendations, published in The Journal of Allergy and Clinical Immunology: In Practice, incorporate national and international guidelines and include a treatment algorithm to guide decision-making.1

“The FDA approval of biologic medication for treating moderate-to-severe AD has transformed the therapeutic landscape highlighting the need for comprehensive and clear guidelines,” said study author Noreen Nicol, PhD, RN, associate professor in the College of Nursing at University of Colorado Anschutz Medical Campus, in a press release. “Without comprehensive guidelines that analyze national and international findings, we risk clinicians skipping crucial conventional steps, such as wet-wrap therapy, that need to be utilized prior to initiating biologics.”2

Diagnosing Severe AD

In the review, lead author Kanwaljit K. Brar, MD, and colleagues defined severe AD as a minimum involvement of 10% body surface area and, regardless of body surface area, individual lesions with severe features, involvement of highly visible areas or those important for function, such as the neck, face, genitals, palms, and/or soles, and significantly impaired quality of life.1 They suggested clinicians use Hanifin and Rajka, UK Working Party, or American Academy of Dermatology Consensus criteria for diagnosing severe AD, although the AAD Consensus criteria has not been validated.
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Validated scoring systems for clinicians include Scoring Atopic Dermatitis (SCORAD) and Eczema Area and Severity Index. In addition, validated scoring systems for patients include Patient-Oriented SCORAD, Patient-Oriented Eczema Measure, and Dermatology Life Quality Index.

Recommendations for Treatment

Brar et al outlines recommendations for nonpharmacologic, pharmacologic, and systemic treatments using the latest evidence. Among the recommendations for nonpharmacologic management of severe AD:

  • Liberal use of moisturizers, preferably bland moisturizers with few irritants and sensitizers, in combination with regular bathing with warm water should be used to maximize skin hydration.
  • Once or twice daily bleach baths can be utilized for patients with recurrent skin infections.
  • Wet wrap therapy should be considered as an option prior to initiating systemic immunosuppressive therapies for patients with moderate to severe AD failing convention therapies. However, wet wrap therapy should be used cautiously and only for patients with moderate-to-severe AD.

Some guidelines on the use of topical corticosteroids (TCS):

  • Lowest effective potency of topical corticosteroids should be used to achieve disease control.
  • Short-term courses of higher potency TCS should be used to control significant flares and a stepwise decrease in potency to the lowest efficacy potency should be used for long-term management.
  • Patients receiving TCS should be monitored for local and systemic adverse effects.
  • Steroid phobia is a contributing factor to nonadherence. Clinicians should educate patients and caregivers when adherence is low and consider other treatment options if counseling does not improve adherence.

“The decision to initiate systemic therapy for patients with severe AD involves a careful reevaluation of the patient’s diagnosis, understanding of their disease including psychosocial aspects, previous treatment, adherence issues, as well as systemic treatment options with risks verses benefits,” Brar et al wrote.1

Systemic options include dupilumab (Dupixent), phototherapy, and immunosuppressant therapies including, cyclosporine, methotrexate, azathioprine, and mycophenolate mofetil. Immunosuppressant therapies are only recommended for short term use due to adverse effects and need for laboratory monitoring.

Practice Pearls

The AD Action plan is recommended to help facilitate discussions and treatment decisions. In addition, Brar et al recommended clinicians:

  • Engage with shared decision-making, which includes listening to the patient or caregiver’s concerns and goals/expectations for treatment, discuss therapeutic options and the risk and benefits of each, consider the patient’s socioeconomic factors and ability adhere to the treatment plan.
  • Discuss the relapsing nature of AD with patients.
  • Work with patients and caregivers to find the right treatment plan that promotes good adherence, as well as provide them with educational materials or support, such as structure educational interventions like eczema school or advocacy groups.

“Life with severe atopic dermatitis can be incredibly difficult for our patients and their families, and it can be quite challenging to care for,” said corresponding author Mark Bogunieqicz, professor in the division of allergy-immunology and department of pediatrics at National Jewish Health and University of Colorado School of Medicine, in a press release. “It is important to let our patients, caregivers, and healthcare providers know that we have entered a new and exciting era in the treatment of AD with a number of targeted therapies approved or being studied which are referenced in this clinical review.”2


1. Brar KK, Nicol NH, Boguniewicz M. Strategies for successful management of severe atopic dermatitis. J Allergy Clin Immunol Pract. 2019;7(1):1-16. doi:10.1016/j.jaip.2018.10.021.

2. Researchers raise bar for successful management of severe atopic dermatitis [press release]. Aurora, CO: University of Colorado Anschutz Medical Campus; January 15, 2019. Accessed February 25, 2019.

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