EADV Updated guideline for treatment of atopic eczema
The European Academy of Dermatology and Venereology has released an updated version of the 2012 guideline on atopic eczema (atopic dermatitis). This guideline was developed as a joint interdisciplinary European project, including physicians from all relevant disciplines as well as patients. It is a consensus‐based guideline, taking available evidence from other guidelines, systematic reviews and published studies into account.
The guideline is drafted by the committee consisting of Andreas Wollenberg, a professor at Ludwig‐Maximilian University, Munich, Germany, and colleagues. This guideline covers methods, patient perspective, general measures and avoidance strategies, basic emollient treatment and bathing, dietary intervention, topical anti‐inflammatory therapy, phototherapy and antipruritic therapy.
The guidelines are published in the Journal of the European Academy of Dermatology and Venereology. The key recommendations of the guideline include:
General measures and avoidance strategies
- Pollen avoidance measures can be recommended during the pollen season.
- House dust mite avoidance measures may be tried in selected cases.
- When classical patch tests are positive, relevant contact allergens should be avoided.
- All children diagnosed with AE should be vaccinated according to the national vaccination plan.
Basic therapy of disturbed skin barrier function and emollient therapy (‘skin care’)
- Adding antiseptics such as sodium hypochlorite to the bathwater may be useful for the treatment of atopic eczema (AE).
- Emollients should be prescribed in adequate amounts, and these should be used liberally and frequently, in a minimum amount of 250 g per week for adults.
- Emollient bath oils and soap substitutes should also be used. Emollients with a higher lipid content are preferable in wintertime.
- A regular use of emollient has a short-and long‐term steroid-sparing effect in mild‐to‐moderate AE. An induction of remission with topical corticosteroids or topical calcineurin inhibitors is required first.
- Patients with moderate‐to‐severe AE should observe a therapeutic diet eliminating those foods that elicitated clinical early or late reactions upon controlled oral provocation tests.
- Primary prevention of food allergy‐associated AE is recommended with exclusive breast milk feeding until 4 months of age.
- If breast milk is lacking in low‐risk children (general population), conventional cow's milk formula is recommended.
- If breast milk is lacking in high‐risk children (one‐first degree relative to physician-diagnosed allergic symptoms), a documented hypoallergenic formula is recommended.
- Introduction of complementary foods is recommended between 4 and 6 months of age in low‐ and high‐risk children irrespective of an atopic heredity.
- A certain diversity of foods selected should be observed during the introduction between 4 and 6 months of age.
Topical anti‐inflammatory therapy
- Topical corticosteroids are important anti‐inflammatory drugs to be used in AE, especially in the acute phase.
- Topical corticosteroids with an improved risk/benefit ratio are recommended in AE.
- Diluted topical corticosteroids may be used under wet wraps for short‐term periods in acute AE to increase their efficacy.
- Proactive therapy, e.g. twice‐weekly application in the long‐term follow‐up, may help to reduce relapses.
- Proactive therapy with topical glucocorticosteroids (TCS) may be used safely for at least 20 weeks, which is the longest duration of trials.
- Patient fear of side‐effects of corticosteroids (corticophobia) should be recognized and adequately addressed to improve adherence and avoid undertreatment.
- Topical calcineurin inhibitors (TCI) are important anti‐inflammatory drugs to be used in AE.
- Instead of treating acute flares with TCI, initial treatment with topical corticosteroids before switching to TCI should be considered.
- TCI is especially indicated in sensitive skin areas (face, intertriginous sites, anogenital area).
- Proactive therapy with a twice‐weekly application of tacrolimus ointment may reduce relapses.
- Effective sun protection should be recommended in patients treated with TCI.
- Medium‐dose ultraviolet A1 (UVA1) and narrowband UVB are recommended for the treatment of AE in adult patients.
- Narrowband UVB is preferred over broadband UVB for AE treatment if available.
- Co‐treatment with topical steroids and emollients should be considered at the beginning of phototherapy to prevent a flare‐up.
- Psoralen and ultraviolet (PUVA) therapy is not the first‐choice therapy for safety profile reasons.
- New devices such as 308‐nm excimer laser are not recommended for the treatment of AE patients.
- Although phototherapy is rarely used in prepubertal children, it is not contraindicated; its use depends rather on feasibility and equipment (NB‐UVB).
- Topical corticosteroids are recommended to control pruritus in the initial phase of AE exacerbation.
- Topical calcineurin inhibitors are recommended to control pruritus in AE until clearance of eczema.
- Topical polidocanol may be used to reduce pruritus in AE patients.
- Routine clinical use of topical antihistamines including doxepin, topical cannabinoid receptor agonists, topical μ‐opioid receptor antagonists or topical anesthetics cannot be recommended as an adjuvant antipruritic therapy in AE.
- There is not enough data available to recommend the use of capsaicin in the management of itch in AE patients.
- There is evidence that UV therapy can be used in AE to relief pruritus. Narrowband UVB and UVA1 seem to be most preferable treatment modalities.
- There is not enough evidence to support the general use of both first‐ and second‐generation H1R antihistamines for the treatment of pruritus in AE. These may be tried for the treatment of pruritus in AE patients if standard treatment with TCS and emollients is not sufficient.
- Long‐term use of sedative antihistamines in childhood may affect sleep quality and is therefore not recommended.
- The opioid receptor antagonists naltrexone and nalmefene are not recommended for routine treatment of itch in AE patients.
- The selective serotonin reuptake inhibitors paroxetine and fluvoxamine are not recommended for routine treatment of itch in AE patients.
For more information click on the link: https://doi.org/10.1111/jdv.14891