Clinical practice guidelines for the diagnosis and management of atopic dermatitis

Key points

• Atopic dermatitis (AD) is diagnosed clinically; the Hanifin and Rajka criteria (3 of 4 major and 3 of 23 minor features) remain the most widely used.
• Basic care means avoiding trigger factors and hydrating the skin: short lukewarm baths and fragrance-free emollients at least twice daily.
• Topical corticosteroids twice daily for flares, topical calcineurin inhibitors for sensitive areas, and twice-weekly proactive therapy for long-term control.
• Severe AD is referred to specialists for phototherapy, systemic immunomodulators or dupilumab.
• A positive allergy test alone should not lead to food avoidance; food allergy should be confirmed by an oral food challenge.

Overview

These Thai clinical practice guidelines, a joint project of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand, give simple algorithms for the diagnosis and management of AD in adults and children. AD is a chronic, relapsing, itchy skin disease affecting up to 20% of children and 1-3% of adults in most countries; treatment aims to reduce symptoms, prevent exacerbations and optimise therapy to avoid treatment risks.

Diagnosis and food allergy

Diagnosis rests on the history and the morphology and distribution of lesions rather than on tests. Skin prick tests, specific IgE and patch tests can identify possible triggers, and a food allergy test may be considered in children with moderate-to-severe AD who do not respond to proper treatment. Because one-third of children with AD who test positive for food allergy have no clinical symptoms, the diagnosis should be confirmed by an oral food challenge after avoiding the suspected food for 2-4 weeks, to prevent unnecessary food avoidance.

Skin care and topical treatment

The guidelines recommend a hypoallergenic soap, water at 27-30°C and baths of 5-10 minutes, followed immediately by an emollient without fragrance or preservatives. For flares, mild-to-moderate (mild AD) or moderate-to-high (moderate-to-severe AD) potency corticosteroids are applied twice daily for 3-7 days until improvement and then gradually reduced; if there is no improvement within 7 days, compliance, infection, misdiagnosis, contact dermatitis or referral should be considered. Topical calcineurin inhibitors are second-line agents suited to the face and intertriginous and anogenital areas: tacrolimus 0.03% for ages 2-16 and 0.1% over 16 years, and pimecrolimus 1% for infants over three months in Thailand. Crisaborole 2% can be used twice daily from three months of age. Antibiotics (1-2 weeks) are used only for bacterial superinfection.

Systemic therapy

Systemic corticosteroids (0.5-1 mg/kg/day for up to 2 weeks) are reserved for exceptional acute flares. Ciclosporin is suggested as first-line short-term treatment for moderate-to-severe AD, starting at 3 mg/kg/day, with azathioprine second-line and methotrexate third-line. Dupilumab is considered for Thai patients aged 12 years and older with an EASI score of at least 20 despite topical treatment whose disease is not controlled by medium-to-high potency topical corticosteroids and at least two systemic therapies, or who cannot discontinue or tolerate them; it is continued if the EASI score falls by at least 50% at 16 weeks.

Prevention and prognosis

Exclusive breastfeeding for three to four months reduces the risk of AD up to two years of age, whereas there is no evidence that dietary avoidance during pregnancy and breastfeeding in high-risk mothers reduces that risk. A meta-analysis found remission in 80% of patients by age eight, and Thai children with mild, moderate and severe AD reached remission at median ages of 3.4, 3.5 and 7.0 years, respectively.

Frequently asked questions

Are oral antihistamines useful?

There is not enough evidence for their general use against itch, but sedating antihistamines may help sleep during flares; topical antihistamines are not recommended.

What is proactive therapy?

Long-term intermittent application of an anti-inflammatory agent, for example twice weekly, to previously affected skin together with emollients, which reduces relapses.

When should patients be referred?

When the diagnosis is doubtful, first-line therapy fails, AD causes significant dysfunction, or immune deficiency or food allergy is suspected.

Source

Kulthanan K, Tuchinda P, Nitiyarom R, Chunharas A, Chantaphakul H, Aunhachoke K, et al. Clinical practice guidelines for the diagnosis and management of atopic dermatitis. Asian Pacific Journal of Allergy and Immunology 2021;39:145-155. DOI: 10.12932/AP-010221-1050. Joint guidelines of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.