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## Complete Summary

#### GUIDELINE TITLE

Disease management of atopic dermatitis: an updated practice parameter.

#### BIBLIOGRAPHIC SOURCE(S)

Leung DY, Nicklas RA, Li JT, Bernstein IL, Blessing-Moore J, Boguniewicz
M, Chapman JA, Khan DA, Lang D, Lee RE, Portnoy JM, Schuller DE, Spector
SL, Tilles SA. Disease management of atopic dermatitis: an updated
practice parameter. Joint Task Force on Practice Parameters. Ann Allergy
Asthma Immunol 2004 Sep;93(3 Suppl 2):S1-21. \[127 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15478395)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Joint Council of Allergy,
Asthma and Immunology. Disease management of atopic dermatitis: a
practice parameter. Ann Allergy Asthma Immunol 1997 Sep;79(3):197-211.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references drugs for which important revised regulatory information has
been released.

-   [June 30, 2008, CellCept (mycophenolate mofetil) and Myfortic
    (mycophenolate
    acid)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#mycophenolate):
    Novartis and Roche have agreed to include additional labeling
    revisions to the WARNINGS and ADVERSE REACTIONS sections of the
    Myfortic and CellCept prescribing information, based on
    post-marketing data regarding cases of Progressive Multifocal
    Leukoencephalopathy (PML) in patients treated with these drugs.

-   [October 29, 2007, CellCept (mycophenolate
    mofetil)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#CellCept2):
    Roche has agreed to include additional labeling revisions to the
    BOXED WARNING, WARNINGS/Pregnancy and Pregnancy Exposure Prevention,
    PRECAUTIONS/Information for Patients, and ADVERSE
    REACTIONS/Postmarketing Experience sections.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Atopic dermatitis

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Treatment

#### CLINICAL SPECIALTY

Allergy and Immunology\
Dermatology\
Family Practice\
Internal Medicine\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide practice parameters for the diagnosis and management of
atopic dermatitis

#### TARGET POPULATION

Infants, children, and adults with atopic dermatitis

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Diagnosis/Evaluation**

1.  Diagnostic criteria of atopic dermatitis

2.  Clinical examination

3.  Laboratory studies (e.g. serum IgE)

4.  Prick skin testing/allergy skin tests

5.  Evaluation of severity of atopic dermatitis

**Treatment/Management**:

1.  Individualized treatment planning

2.  First-line treatment

    -   Skin hydration with moisturizers and emollients (lotions,
        creams, and ointments)

    -   Topical corticosteroids

    -   Topical calcineurin inhibitors (pimecrolimus. tacrolimus)

    -   Tar preparation

    -   Oral antihistamines Note: Topical antihistamines not generally
        recommended

    -   Identification and elimination of triggering factors irritants,
        allergens, emotional stressors, infectious agents (antibiotics
        as indicated for infection

3.  Alternative treatment

    -   Application of wet dressings in combination with topical
        corticosteroids

    -   Short-term treatment with systemic corticosteroids with
        appropriate tapering to avoid rebound

    -   Phototherapy with ultraviolet light

    -   Immunomodulatory or immunosuppressive agents

    -   Hospitalization to separate the patient from environmental
        allergens while administering other therapies

    -   Allergen immunotherapy when aeroallergens are clearly implicated
        in dermatitis flares

    -   Risk-benefit analysis of alternative therapies

4.  Investigational treatment

5.  Patient education

6.  Consultation with atopic dermatitis specialist

7.  Ongoing evaluation and follow-up

#### MAJOR OUTCOMES CONSIDERED

-   Efficacy of management interventions at relieving symptoms and
    reducing cutaneous inflammation

-   Quality of life (lost work days, lost school days, sleep
    disturbance)

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The Joint Task Force revised the initial draft into a working draft of
the document, which included a review of the medical literature using a
variety of engines such as PubMed.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Category of Evidence**

Ia Evidence from meta-analysis of randomized controlled trials

Ib Evidence from at least 1 randomized controlled trial

IIa Evidence from at least 1 controlled study without randomization

IIb Evidence from at least 1 other type of quasi-experimental study

III Evidence from nonexperimental descriptive studies, such as
comparative studies, correlation studies, and case-control studies

IV Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both

LB Evidence from laboratory-based studies

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Published clinical studies were rated by category of evidence and used
to establish the strength of a clinical recommendation.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

A.  Directly based on category I evidence

B.  Directly based on category II evidence or extrapolated from category
    I evidence

C.  Directly based on category III evidence or extrapolated from
    category I or II evidence

D.  Directly based on category IV evidence or extrapolated from category
    I, II, or III evidence

E.  Directly based on category LB evidence

F.  Based on consensus of the Joint Task Force on Practice Parameters

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The 3 national allergy and immunology societies, the American College of
Allergy, Asthma, and Immunology (ACAAI), the American Academy of
Allergy, Asthma, and Immunology (AAAAI), and the Joint Council of
Allergy, Asthma, and Immunology (JCAAI), have given the Task Force the
responsibility for updating existing parameters. This document builds on
the original Parameter on Atopic Dermatitis. It was written and reviewed
by subspecialists in allergy and immunology and was funded by the 3
allergy and immunology organizations noted above. Donald Y. M. Leung,
MD, PhD, who chaired the workgroup that developed the original Parameter
on Atopic Dermatitis, prepared the initial draft of the updated
parameter on this condition. The Joint Task Force revised the initial
draft into a working draft of the document, which included a review of
the medical literature using a variety of search engines such as PubMed.
The working draft of the updated Parameter on Atopic Dermatitis was then
reviewed by a number of experts in allergy and immunology and
specifically by experts on atopic dermatitis. This document, therefore,
represents an evidence-based, broadly accepted consensus opinion.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

This practice parameter includes an algorithm on the diagnosis and
management of atopic dermatitis accompanied by annotations (numbered to
correspond with the algorithm). Guideline recommendations are presented
in the form of summary statements. After each statement is a letter in
parentheses that indicates the strength of the recommendation.
Categories of evidence (Ia, Ib, IIa, IIb, III, IV, LB) and strength of
recommendations (A-F) are defined at the end of the \"Major
Recommendations\" field.

**[Annotations]{.underline}**

**Annotation 1: Patient Presents with Skin Manifestations Consistent
with Atopic Dermatitis (e.g., an Eczematous Pruritic Dermatitis)**

There is no objective laboratory test for the diagnosis of atopic
dermatitis. Therefore, the diagnosis of atopic dermatitis is based on a
constellation of clinical features. These include (1) the essential
feature, which is a pruritic dermatitis; (2) typical features, such as
facial and extensor eczema in infants and children, flexural eczema in
adults, and chronic or relapsing dermatitis; (3) frequently associated
features, such as personal or family history of atopic disease, xerosis,
cutaneous infections, nonspecific dermatitis of the hands or feet,
elevated serum immunoglobulin E (IgE) levels, frequent occurrence of
nonspecific decrease in cell-mediated immune response (anergy), positive
immediate-type allergy skin tests and early age of onset; and (4) other
features, such as white dermatographism and delayed blanch response,
anterior subcapsular cataracts, keratoconus, Dennie-Morgan infraorbital
folds, orbital darkening, facial erythema, or pallor.

**Annotation 2: Evaluation Based on History and Physical Examination
Diagnostic for Atopic Dermatitis?**

Atopic dermatitis often is associated with an early age of onset, with
approximately 80% of cases starting before the age of 5 years. It
frequently is associated with respiratory allergy and a number of other
features, such as Dennie-Morgan infraorbital folds, white
dermatographism, and facial pallor.

Acute and subacute lesions of atopic dermatitis are characterized by
intensely pruritic, erythematous papulovesicles associated with
excoriation and serous exudate. Lesions that do not appear
papulovesicular clinically must demonstrate spongiosis histologically.
Chronic atopic dermatitis is characterized by lichenification, papules,
and excoriations. At all stages of atopic dermatitis, patients usually
have dry skin. The distribution and skin reaction pattern vary according
to the patient\'s age and disease activity. The skin distribution
pattern in infants and young children generally involves the face, neck,
and extensor skin surfaces. In contrast, in older children and adults
who have long-standing skin disease, lichenification and localization of
the rash to the flexural folds of the extremities usually are found.
Chronic hand (and/or foot) eczema may be the primary or sole
manifestation of many atopic adults.

**Annotation 3: Consideration of Other Conditions**

A firm diagnosis of atopic dermatitis depends on the exclusion of other
skin conditions with similar symptoms and signs. Failure of any response
to \"standardized\" management of atopic dermatitis is a reason to
consider other eczematous conditions. Skin conditions that may mimic
atopic dermatitis fall into the following categories: (1) chronic
dermatoses, such as seborrheic and contact dermatitis, nummular eczema,
psoriasis, and ichthyoses; (2) infections and infestations such as
scabies, human immunodeficiency virus, and dermophytosis; (3)
malignancies, such as cutaneous T-cell lymphoma and Letterer-Siwe
disease; (4) immunologic disorders, such as dermatitis herpetiformis,
graft-vs-host disease, and dermatomyositis; (5) immunodeficiencies, such
as Wiskott-Aldrich, severe combined immunodeficiency disease, hyper-IgE,
and DiGeorge syndrome; and (6) metabolic disorders, such as zinc,
pyridoxine, or niacin deficiency and phenylketonuria. In situations in
which the diagnosis is not obvious, a skin biopsy should be considered.
The skin biopsy should be performed by a physician trained and
experienced in performing the procedure and should be interpreted by a
qualified dermatopathologist.

**Annotation 4: Is the Atopic Dermatitis Severe?**

Severe atopic dermatitis is characterized by intensely pruritic,
widespread skin lesions that often are complicated by persistent
bacterial, viral, or fungal infections. The presence of keratoconus,
keratoconjunctivitis, anterior cataracts, and eczema vaccinatum suggests
that the atopic dermatitis is particularly severe, which may be related
to chronicity.

The extent and severity of atopic dermatitis can be determined by
careful examination of the patient\'s skin, grading the extent of
affected areas (e.g., percentage of involvement of the head, upper
limbs, trunk, and lower limbs), and defining the severity of the
following signs of eczema: induration, erythema, excoriation,
lichenification, scaling, oozing, weeping, and crusting. In general,
patients who have more than 20% skin involvement (or 10% of skin
involvement if affected areas include the eyelids, hands, or
intertriginous areas) that has not been responsive to first-line
treatment should be considered for consultation with a specialist. Other
patients who should be considered as having severe atopic dermatitis
include:

-   Patients with extensive skin involvement who are at risk for
    exfoliation

-   Patients who require ongoing or frequent treatment with high-potency
    topical glucocorticoids or systemic glucocorticoids

-   Patients who require hospitalization for severe eczema or skin
    infections related to the atopic dermatitis

-   Patients with ocular or infectious complications

-   Patients who have significant disruption of their quality of life
    (e.g., sleepless nights, school or work days lost)

-   Patients who are generally erythrodermic

Patients not previously receiving appropriate treatment for atopic
dermatitis should be started on first-line therapy, and attempts should
be made to identify potential triggers.

**Annotation 5: Management of Atopic Dermatitis**

The treatment of atopic dermatitis is directed at symptom relief and
reduction of cutaneous inflammation. Characterization of each patient\'s
skin disease severity and the reduction of exacerbating factors are
critical for effective management. All patients require skin hydration
in combination with an effective emollient. Potential trigger factors
should be identified and eliminated. These include irritants, allergens,
and emotional stresses. Therapy must be individualized and is dependent
on whether the patient is experiencing an acute flare or dealing with
the management of chronic atopic dermatitis.

The severity of atopic dermatitis is based on the extent of skin
involvement, the intensity of pruritus, the presence of complications,
the effect on quality of life, and the amount of medication required for
control.

The initial management of atopic dermatitis may consist of the following
categories of treatment: hydration, topical corticosteroids, topical
calcineurin inhibitors, tar preparations, and antihistamines.

Tacrolimus, a calcineurin inhibitor, has been shown to be effective and
safe for use in atopic dermatitis. Most patients experience a dramatic
reduction of pruritus within 3 days of initiating treatment, as well as
significant improvement in quality of life. Pimecrolimus also has been
shown to be effective and safe for the treatment of atopic dermatitis.
When used as long-term maintenance therapy, topical preparations of this
drug reduce the number of flares of atopic dermatitis and the
requirement for corticosteroid treatment.

There are many factors that may contribute to exacerbations of atopic
dermatitis, including food allergens, aeroallergens, infections,
temperature, humidity, irritants, and emotional stress.

Skin testing or in vitro testing for IgE antibodies can be useful in the
identification of potential allergens. In particular, negative skin
tests or in vitro tests can be used to exclude allergic trigger factors
as a cause of atopic dermatitis. Positive skin test results or in vitro
test results do not prove that a particular allergen causes clinical
symptoms, but they may guide the clinician in considering possible
causes. This is particularly true in the case of foods, where controlled
food challenges or elimination diets may be needed to confirm or exclude
clinical sensitivity to foods.

Skin infections should be treated with short courses of appropriate
antimicrobial therapy, with an emphasis on appropriate treatment for
staphylococcal infections. Herpetic and dermatophytic infections also
need to be considered and treated after appropriate diagnosis has been
confirmed.

**Annotation 6: Is the Management Successful?**

Response to therapy may be classified as a complete response, a partial
response, or a treatment failure. Complete response and eradication of
the patient\'s eczema, in the short term, is unusual unless there is a
clear-cut trigger (e.g., a food allergen that could be eliminated).
Atopic dermatitis is a chronic relapsing skin condition, and therefore
most patients will have a partial response with reduction in pruritus
and the extent of skin disease. These patients will need long-term
follow-up for adjustment of medications according to the severity of the
illness. Patients who do not respond to treatment should be completely
reassessed to be certain of the diagnosis, and alternative treatment
should be considered.

**Annotation 7: Follow-up**

To achieve effective control of a patient\'s atopic dermatitis, it is
important to educate patients and family members about the chronic
nature of their disease, exacerbating factors, and appropriate treatment
options. This is important to ensure cooperation and compliance with the
treatment plan. Written information that includes detailed skin care
recommendations, environmental control, and general information about
the disease should be provided. Patients should be educated on how to
monitor their disease and know how to respond to changes in their status
and when to seek additional medical help. The treatment plan should be
reviewed during follow-up visits, and the patient and/or parent should
demonstrate an appropriate level of understanding to ensure a good
outcome. Adequate time and teaching materials are necessary to provide
effective education. Patient support organizations that provide updates
on progress in atopic dermatitis research are important resources for
these patients. Follow-up of patients with atopic dermatitis also should
include evaluation for potential triggers of exacerbations (e.g.,
aeroallergens, infection, emotional factors) and cooperative management
with the patient and/or parent to prevent such exacerbations.

**Annotation 8: Reassess: Is Diagnosis of Atopic Dermatitis Correct?**

In patients who do not achieve the goals of atopic dermatitis
management, it is important to reassess whether the diagnosis is
correct. With the lack of a characteristic skin lesion or a confirmatory
laboratory test result, the diagnosis depends on clinical symptoms and
the physical examination. Concomitant allergic rhinitis and/or asthma
increase the likelihood that the diagnosis of atopic dermatitis is
correct. As discussed in annotation 1, many skin conditions may
masquerade as atopic dermatitis.

When reassessing patients, it is helpful to consider the following
points. Most patients who present with atopic dermatitis are younger
than 5 years but are infrequently younger than 6 weeks. Any infant with
an eczematous rash presenting earlier than the first month of life
should be carefully evaluated for the presence of congenital
immunodeficiency, particularly if the course is complicated by recurrent
infections and failure to thrive. Atopic dermatitis does not usually
affect the diaper area or the nose exclusively. Differentiation of
seborrheic dermatitis from atopic dermatitis may be difficult in
infants. It is important to consider contact dermatitis and skin
infections as complicating factors.

**Annotation 9: Consultation with an Atopic Dermatitis Specialist for
Consideration of Other Conditions**

Patients who are refractory to first-line therapy and who have severe
atopic dermatitis with significant dysfunction should have a
consultation with an atopic dermatitis specialist, such as an allergist
or dermatologist. Such consultation is recommended when the diagnosis of
atopic dermatitis is in doubt and for identification of potential
allergen triggers, patient education, and implementation of alternative
therapies, including potent anti-inflammatory and immunomodulatory
agents.

Cooperation between the patient and/or the patient\'s guardian(s), the
primary care physician, and the allergist or dermatologist is important
in the implementation of strategies necessary for the care of patients
with chronic atopic dermatitis. Even when an atopic dermatitis
specialist is consulted, the primary care physician continues to play an
important role in the care of patients with atopic dermatitis by
ensuring continuity of care.

**Annotation 10: Consultation with an Atopic Dermatitis Specialist:
Intensification of Management and Treatment**

When atopic dermatitis is either severe or has not responded to
appropriate first-line management strategies, specialist consultation
should be obtained. This allows both a reevaluation of first-line
treatment approaches (e.g., hydration, emollients, topical
corticosteroids, pimecrolimus, tacrolimus, and tar preparations) and
consideration of alternative therapy. Examples of alternative strategies
include (1) the application of wet dressings in combination with topical
corticosteroids; (2) short-term treatment with systemic corticosteroids
with appropriate tapering to avoid rebound; (3) phototherapy with
ultraviolet light (UV-B or UV-A \[PUVA\]); (4) immunomodulatory or
immunosuppressive agents; (5) hospitalization to separate the patient
from environmental allergens while administering other therapies; and
(6) allergen immunotherapy when aeroallergens are clearly implicated in
dermatitis flares. In light of potential adverse effects, a careful
risk-benefit analysis should be undertaken before initiating any of
these alternative therapies. For patients who do not respond to these
approaches, investigational treatment can be considered.

**[Summary Statements]{.underline}**

**Definitions**

Summary Statement 1. Atopic dermatitis is a familial, chronic
inflammatory skin disease that commonly presents during early infancy
and childhood but can persist or start in adulthood. (C)

**Immunopathology**

Summary Statement 2. Most individuals with atopic dermatitis have
elevated serum IgE levels, which are often very high. (C)

Summary Statement 3. Pathogenesis of atopic dermatitis involves a
complex inflammatory process associated with IgE-bearing Langerhans
cells, atopic keratinocytes, lymphocytes, monocytes/macrophages,
eosinophils, and mast cells. (C)

Summary Statement 4. There is an increased frequency of T~H~2 cells
producing interleukin (IL)-4, IL-5, and IL-13, but little
interferon-gamma has been found in the peripheral blood and acute skin
lesions of patients with atopic dermatitis. The clinical manifestations
of atopic dermatitis result in large part from stimulation of the T~H~2
wing of the immunologic pathways. (C)

Summary Statement 5. There is a complex interaction among susceptibility
genes, the host environment, and multiple immunologic cells, leading to
acute and chronic lesions that characterize this skin disease. (B)

**Clinical Diagnosis**

Summary Statement 6. There is no objective diagnostic test for the
clinical confirmation of atopic dermatitis. (D)

Summary Statement 7. The diagnosis of atopic dermatitis is based on a
constellation of clinical features. (D)

Summary Statement 8. Pruritus and chronic or relapsing eczematous
lesions with typical morphology and distribution in patients with a
history of atopy are essential for diagnosis. (F)

Summary Statement 9. Acute and subacute skin lesions are most often seen
in infants and young children and are characterized by intensely
pruritic erythematous papulovesicular lesions associated with
excoriation and serous exudate. (D)

Summary Statement 10. Chronic atopic dermatitis is characterized by
lichenification, papules, and excoriations. (D)

**First-line Management and Treatment**

Summary Statement 11. The intensity of management and treatment of
atopic dermatitis is dictated by the severity of illness, which relates
to the effect of atopic dermatitis on the quality of life of the patient
and his or her family. (A)

Summary Statement 12. Successful management requires a systematic,
multipronged approach that includes antipruritic therapy, skin
hydration, topical anti-inflammatory medications, and the identification
and possible elimination of exacerbating factors. (A)

*Skin Hydration*

Summary Statement 13. Atopic dermatitis is characterized by reduced skin
barrier function due to loss of vital lipids, which leads to enhanced
water loss and dry skin. (E)

Summary Statement 14. Moisturizers such as lukewarm soaking baths for at
least 20 minutes followed by the application of an occlusive emollient
to retain moisture can give the patient symptomatic relief. (D)

Summary Statement 15. Emollients, available in the form of lotions,
creams, and ointments, should be used as first-line therapy. (D)

*Topical Corticosteroids*

Summary Statement 16. Topical corticosteroids, applied to areas of
eczema, are effective treatment for atopic dermatitis. (A)

Summary Statement 17. Low-potency corticosteroids are recommended for
maintenance therapy, whereas intermediate-and high-potency
corticosteroids should be used for the treatment of clinical
exacerbation and applied to affected areas of skin over short periods of
time. (A)

Summary Statement 18. Potent fluorinated corticosteroids should be
avoided on the face, the eyelids, the genitalia, and the intertriginous
areas, as well as in young infants. (D)

Summary Statement 19. Ultrahigh-potency corticosteroids should be used
only for very short periods of time (several days) and only in areas
that are lichenified. (D)

Summary Statement 20. The degree of corticosteroid absorption through
the skin, and hence the potential for systemic adverse effects, is
directly dependent on the surface area of the skin involved, the use of
occlusive dressing, and the potency of the corticosteroid preparation.
(D)

*Topical Calcineurin Inhibitors*

[Tacrolimus]{.underline}

Summary Statement 21. Tacrolimus ointment has been shown to be effective
and safe in both adults and children for the treatment of
mild-to-moderately severe atopic dermatitis, with most patients
experiencing a reduction of pruritus within 3 days of initiating
therapy. (A)

Summary Statement 22. Tacrolimus ointment applied on up to 100% of the
body surface in adults and children has demonstrated sustained efficacy
with no significant systemic adverse effects. (A)

Summary Statement 23. A local burning sensation is the most common
adverse effect associated with tacrolimus. This may limit its usefulness
in certain patients. (A)

Summary Statement 24. Tacrolimus ointment can be used safely for facial
and eyelid eczema. (D)

[Pimecrolimus]{.underline}

Summary Statement 25. Topical pimecrolimus cream is a calcineurin
inhibitor that decreases the number of flares of atopic dermatitis,
reduces the need for corticosteroids, and controls pruritus. (A)

*Tar Preparations*

Summary Statement 26. Although tar preparations are widely used in the
treatment of atopic dermatitis, there are no randomized, controlled
studies that have demonstrated their efficacy. (A)

Summary Statement 27. Newer coal tar products have been developed that
are more cosmetically acceptable, with respect to odor and staining of
clothes, than some older products. (B)

Summary Statement 28. Tar preparations should not be used on acutely
inflamed skin, since this may result in additional skin irritation. (D)

*Antihistamines*

Summary Statement 29. Some patients may benefit from the use of
antihistamines for the relief of pruritus associated with atopic
dermatitis. (C)

Summary Statement 30. Treatment of atopic dermatitis with topical
antihistamines is generally not recommended because of potential
cutaneous sensitization. (C)

**Identification and Elimination of Triggering Factors**

Summary Statement 31. Avoidance of common irritants (e.g., soaps,
toiletries, wool, chemicals) that trigger the itch-scratch cycle is
recommended. (B)

Summary Statement 32. Control of temperature and humidity may be useful
for preventing pruritus. (D)

Summary Statement 33. Aeroallergens such as house dust mites, animal
allergens, and pollens may cause exacerbation, and therefore exposure to
them should be minimized. (A)

Summary Statement 34. Possible allergenic triggers of atopic dermatitis
can be confirmed by skin tests and in vitro tests for specific IgE
antibodies and in some cases by patch tests that may produce immediate
or delayed reactions to protein allergens. (B)

Summary Statement 35. Food allergens trigger atopic dermatitis more
commonly in young infants and children than in adults. (D)

**Microbes**

Summary Statement 36. Patients with moderate-to-severe atopic dermatitis
have been found to make IgE antibodies against staphylococcal toxins
present on their skin. (B)

Summary Statement 37. A course of an appropriate systemic antibiotic
should be considered in patients who are heavily colonized or infected
with staphylococcal aureus. Antibiotic treatment maybe more difficult if
staphylococcal aureus is resistant. (D)

Summary Statement 38. Atopic dermatitis can be complicated by recurrent
viral skin infections, such as herpes simplex, warts, and molluscum
contagiosum. (D)

Summary Statement 39. Smallpox vaccination or even exposure of patients
with atopic dermatitis to recently vaccinated individuals may cause a
severe, widespread, potentially fatal dermatitis called eczema
vaccinatum, which is similar in appearance to eczema herpeticum. (C)

Summary Statement 40. Dermatophytic infections can complicate atopic
dermatitis and may contribute to exacerbation (D) of disease activity.
(LB)

**Emotional Stress**

Summary Statement 41. Emotional factors do not cause atopic dermatitis
but often cause exacerbation and have been found to induce immune
activation as well as increase pruritus and scratching. (D)

**Patient Education**

Summary Statement 42. To achieve effective control of atopic dermatitis,
it is important to educate patients and family members about the chronic
nature of atopic dermatitis, exacerbating factors, and appropriate
treatment options, including patient support organizations to enhance
adherence. (B)

**Treatment of the Difficult-to-Manage Patient**

*Wet Dressing and Occlusion*

Summary Statement 43. Wet dressings may serve as an effective barrier
against persistent scratching, allowing more rapid healing of excoriated
lesions. (B)

Summary Statement 44. Application of wet-wrap dressings in combination
with topical corticosteroids can be efficacious in the treatment of
refractory atopic dermatitis. (A)

*Allergen Immunotherapy*

Summary Statement 45. Although the effectiveness of allergen
immunotherapy in the treatment of atopic dermatitis has not been
conclusively demonstrated, there are selected patients with atopic
dermatitis who may benefit from such treatment. (F)

*Systemic Corticosteroids*

Summary Statement 46. The use of systemic corticosteroids may be
required in the treatment of severe, recalcitrant chronic atopic
dermatitis. (F)

Summary Statement 47. The dramatic clinical improvement that may occur
after administration of systemic corticosteroids may be associated with
an equally dramatic rebound flaring of atopic dermatitis following
discontinuation of systemic corticosteroids. (D)

*Phototherapy*

Summary Statement 48. Natural sunlight can be beneficial for atopic
dermatitis, but sunburn and overheating should be avoided. (A)

Summary Statement 49. Ultraviolet therapy can be a useful adjunct in the
treatment of recalcitrant atopic dermatitis. (D)

Summary Statement 50. Phototherapy with ultra-violet light A (PUVA)
should be restricted to patients with recalcitrant atopic dermatitis.
(B)

*Systemic Immunomodulating Agents*

Summary Statement 51. Immunosuppressive agents such as cyclosporin,
interferon gamma, mycophenolate mofetil, and azathioprine have been
shown to provide benefit for certain cases of severe refractory atopic
dermatitis, but potential benefits should be weighed against their
potentially serious adverse effects. (F)

*Hospitalization*

Summary Statement 52. Hospitalization can result in an improvement in
atopic dermatitis by removing the patient from environmental allergens
and irritants and by providing patient education and improving
compliance. (D)

*Investigative Approaches*

Summary Statement 53. There are certain investigative treatments that
have been proposed for the management of atopic dermatitis. These remain
unproven at this time. (D)

*Consultation with an Atopic Dermatitis Specialist*

Summary Statement 54. Patients refractory to first-line therapy should
be evaluated by an atopic dermatitis specialist. (F)

**[Definitions]{.underline}**:

**Strength of Recommendations**

A.  Directly based on category I evidence

B.  Directly based on category II evidence or extrapolated from category
    I evidence

C.  Directly based on category III evidence or extrapolated from
    category I or II evidence

D.  Directly based on category IV evidence or extrapolated from category
    I, II, or III evidence

E.  Directly based on category LB evidence

F.  Based on consensus of the Joint Task Force on Practice Parameters

**Category of Evidence**

Ia Evidence from meta-analysis of randomized controlled trials

Ib Evidence from at least 1 randomized controlled trial

IIa Evidence from at least 1 controlled study without randomization

IIb Evidence from at least 1 other type of quasi-experimental study

III Evidence from nonexperimental descriptive studies, such as
comparative studies, correlation studies, and case control studies

IV Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both

LB Evidence from laboratory-based studies

#### CLINICAL ALGORITHM(S)

An algorithm is provided in the original guideline document for the
diagnosis and management of atopic dermatitis.

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified for each recommendation
(see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Accurate diagnosis, evaluation, and management of atopic dermatitis

-   Relief of symptoms

-   Reduction in cutaneous inflammation

#### POTENTIAL HARMS

-   *Skin hydration*: Lotions and creams may be irritating due to
    preservatives, solubilizers, and fragrances. Lotions also contain
    water and may be drying due to an evaporative effect. Occlusive
    ointments are sometimes not well tolerated because of interference
    with the function of the eccrine sweat ducts and may induce the
    development of a sweat retention dermatitis. An increased incidence
    of peanut allergy has been reported in children in the United
    Kingdom using emollients with refined peanut oil for atopic
    dermatitis.

-   *Topical corticosteroids*: Certain areas of the body, including the
    mucous membranes, the genitalia, the eyelids, the face, and
    intertriginous areas, have increased potential for transepidermal
    corticosteroid penetration, and for this reason, potent fluorinated
    corticosteroids should be avoided in these areas. Adverse effects
    from topical corticosteroids are directly related to the potency
    ranking of the compound and the duration of use. It is incumbent on
    the clinician to balance the need for therapeutic potency with the
    potential for adverse effects. Adverse effects from topical
    corticosteroids can be divided into local and systemic adverse
    effects. The latter, which occurs rarely, includes suppression of
    the hypothalamic-pituitary-adrenal axis. Local adverse effects
    include the development of striae and atrophy of the skin, perioral
    dermatitis, rosacea, and allergic contact dermatitis (due to the
    vehicle in most cases and after use of nonfluorinated
    corticosteroids). Systemic adverse effects are related to the
    potency of the topical corticosteroid, the site of application, the
    occlusiveness of the preparation, the percentage of the body
    covered, and the length of use. The potential for prolonged use of
    potent topical corticosteroids to cause adrenal suppression is
    greatest in small children and infants.

-   *Tacrolimus*: A local burning sensation is the most common adverse
    effect associated with tacrolimus.

-   *Tar preparations* should not be used on acutely inflamed skin,
    since this may result in additional skin irritation. There is a
    theoretical risk of tar being a carcinogen based on observational
    studies of workers using tar components in their occupation. Adverse
    effects associated with tars include folliculitis and, occasionally,
    photosensitivity.

-   *Wet dressings*: Patients should be monitored carefully for
    secondary microbial infection and adrenal suppression when wet-wrap
    dressings are used for prolonged periods in combination with potency
    corticosteroids.

-   *Phototherapy*: Short-term adverse effects from phototherapy may
    include erythema, skin pain, pruritus, and pigmentation. Potential
    long-term adverse effects include premature skin aging and cutaneous
    malignancies. Sunburn and overheating should be avoided with natural
    sunlight

-   *Systemic immunomodulating agents*: Immunosuppressive agents such as
    cyclosporin, interferon gamma, mycophenolate mofetil, and
    azathioprine may have potentially serious adverse effects.

    -   *Cyclosporin*: nausea, abdominal discomfort, hypertrichosis,
        paresthesias, hypertension, hyperbilirubinemia, renal impairment

    -   *Interferon gamma*: influenza-like symptoms early in the
        treatment course

    -   *Mycophenolate mofetil*: occasional herpes retinitis and
        dose-related bone marrow suppression

    -   *Azathioprine*: myelosuppression

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   This parameter was edited by Dr. Nicklas in his private capacity and
    not in his capacity as a medical officer with the Food and Drug
    Administration. No official support or endorsement by the Food and
    Drug Administration is intended or should be inferred.

-   This is complete and comprehensive document at the current time. The
    medical environment is a changing environment and not all
    recommendations will be appropriate for all patients.

-   Because this document incorporated the efforts of many participants,
    no single individual, including those who served on the Joint Task
    Force, is authorized to provide an official American Academy of
    Allergy, Asthma, and Immunology (AAAAI) or American College of
    Allergy, Asthma, and Immunology (ACAAI) interpretation of these
    practice parameters. Any request for information about or an
    interpretation of these practice parameters by the AAAAI of the
    ACAAI should be directed to the Executive Offices of the AAAAI, the
    ACAAI, and the Joint Council of Allergy, Asthma, & Immunology
    (JCAAI).

-   These parameters are not designed for use by pharmaceutical
    companies in drug promotion.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Clinical Algorithm

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Getting Better\
Living with Illness

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Leung DY, Nicklas RA, Li JT, Bernstein IL, Blessing-Moore J, Boguniewicz
M, Chapman JA, Khan DA, Lang D, Lee RE, Portnoy JM, Schuller DE, Spector
SL, Tilles SA. Disease management of atopic dermatitis: an updated
practice parameter. Joint Task Force on Practice Parameters. Ann Allergy
Asthma Immunol 2004 Sep;93(3 Suppl 2):S1-21. \[127 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15478395)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1997 Sep (revised 2004 Sep)

#### GUIDELINE DEVELOPER(S)

American Academy of Allergy, Asthma and Immunology - Medical Specialty
Society\
American College of Allergy, Asthma and Immunology - Medical Specialty
Society\
Joint Council of Allergy, Asthma and Immunology - Medical Specialty
Society

#### GUIDELINE DEVELOPER COMMENT

These guidelines were developed by the Joint Task Force on Practice
Parameters for Allergy and Immunology, which is sponsored by the
American Academy of Allergy, Asthma, and Immunology, the American
College of Allergy, Asthma, and Immunology and the Joint Council of
Allergy, Asthma and Immunology.

#### SOURCE(S) OF FUNDING

Funded by the American Academy of Allergy, Asthma, and Immunology
(AAAAI), the American College of Allergy, Asthma, and Immunology
(ACAAI), and the Joint Council of Allergy, Asthma, and Immunology
(JCAAI).

#### GUIDELINE COMMITTEE

Joint Task Force on Practice Parameters

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Working Group on Atopic Dermatitis*: Donald Y. M. Leung, MD, Division
of Pediatric Allergy-Immunology, Department of Pediatrics, National
Jewish Medical and Research Center and University of Colorado Health
Sciences Center, Denver, Colorado; Richard A. Nicklas, MD, Department of
Medicine, Uniformed Services, University of Health Sciences, George
Washington University Medical Center, Bethesda, Maryland; James T. Li,
MD, Department of Medicine, Mayo Clinic and Foundation, Rochester,
Minnesota; I. Leonard Bernstein, MD, Department of Medicine, Division of
Immunology, University of Cincinnati College of Medicine, Cincinnati,
Ohio; Joann Blessing-Moore, MD, Department of Immunology, Stanford
University Hospital, Palo Alto, California; Mark Boguniewicz, MD,
Division of Pediatric Allergy-Immunology, Department of Pediatrics,
National Jewish Medical and Research Center and University of Colorado
School of Medicine, Denver, Colorado; Jean A. Chapman, MD, Retired, Cape
Girardeau , Missouri; David A. Khan, MD, Department of Internal
Medicine, Division of Allergy and Immunology, University of Texas
Southwestern Medical Center, Dallas, Texas; David Lang, MD,
Allergy/Immunology Section, Division of Medicine, Cleveland Clinic
Foundation, Cleveland, Ohio; Rufus E. Lee, MD, Private practice, Dothan,
Alabama; Jay M. Portnoy, MD, Section of Allergy, Asthma & Immunology,
Children\'s Mercy Hospital, Kansas City, Missouri; Diane E. Schuller,
MD, Department of Pediatrics, Allergy, Immunology and Pulmonology, Penn
State University, Milton S. Hershey Medical College, Hershey ,
Pennsylvania; Sheldon L. Spector, MD, Department of Medicine, UCLA
School of Medicine, and California Allergy and Asthma Medical Group, Los
Angeles, California; Stephen A. Tilles, MD, Asthma Inc, and Department
of Medicine, University of Washington School of Medicine, Seattle,
Washington

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### ENDORSER(S)

American Academy of Pediatrics - Medical Specialty Society

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Joint Council of Allergy,
Asthma and Immunology. Disease management of atopic dermatitis: a
practice parameter. Ann Allergy Asthma Immunol 1997 Sep;79(3):197-211.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Joint Council of Allergy, Asthma,
and Immunology (JCAAI) Web
site](http://www.jcaai.readyportal.net/file_depot/0-10000000/20000-30000/27387/folder/63948/AtopicDerm2004.pdf).

Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3 Palatine, IL
60067.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This summary was completed by ECRI on October 1, 1998. The information
was verified by the guideline developer on December 15, 1998. This NGC
summary was updated by ECRI on May 9, 2005. The updated information was
verified by the guideline developer on May 23, 2005. This summary was
updated by ECRI on January 31, 2006, following release of a public
health advisory from the U.S. Food and Drug Administration regarding the
use of Elidel Cream (pimecrolimus) and Protopic Ointment (tacrolimus).
This summary was updated by ECRI Institute on November 6, 2007,
following the U.S. Food and Drug Administration advisory on CellCept
(mycophenolate mofetil). This summary was updated by ECRI Institute on
July 8, 2008, following the updated U.S. Food and Drug Administration
(FDA) advisory on CellCept (mycophenolate mofetil) and Myfortic
(mycophenolate acid).

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Reproduced with the
permission from the American College of Allergy, Asthma, and Immunology.

### DISCLAIMER

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Date Modified: 11/3/2008