Bibliographic Source(s)

• Hanifin JM Cooper KD Ho VC Kang S Krafchik BR Margolis DJ Schachner LA Sidbury R Whitmore SE Sieck CK Van Voorhees AS. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004 Mar;50(3):391-404. [212 references] PubMed

Guideline Status

This is the current release of the guideline.

Guideline Category

Management
Treatment

Intended Users

Physicians

Guideline Objective(s)

To address the management of patients with atopic dermatitis or atopic eczema

Target Population

Children and adults with atopic dermatitis or atopic eczema

Interventions and Practices Considered

Refer to the "Major Recommendations" field for context.

1. Topical corticosteroids
2. Other topical therapies such as emollients calcineurin inhibitors tacrolimus (FK-506/Protopic®) pimecrolimus (ASM 981/Elidel®) coal tar doxepin phosphodiesterase inhibitors
3. Antibiotics and antiseptics (systemic and topical)
4. Oral antihistamines
5. Dietary restrictions (in established atopic dermatitis)
   • Dietary restriction of eggs
   • Evening primrose oil fish oil and borage oil
   • Pyridoxine vitamin E and multivitamins and zinc supplementation
   • Probiotics
6. Non-pharmacological interventions
   • Psychological approaches such as behavior modification stress reduction techniques group psychotherapeutic treatments
   • Nurse education
   • Ultraviolet (UV) phototherapy
   • House dust mite reduction
   • Avoidance of enzyme-enriched detergents
   • Specialized clothing
   • Balneotherapy
7. Systemic immunomodulary agents
   • Cyclosporin A
   • Interferon-gamma
   • Systemic Corticosteroids
   • Azathioprine
   • Mycophenolate mofetil
   • Intravenous immunoglobulin
   • Leukotriene inhibitors
   • Methotrexate
   • Desensitization injections
   • Theophylline and papaverine
   • Thymopentin
   • Tumor necrosis factor inhibitors
   • Oral pimecrolimus
   • Allergen-antibody complexes of house dust mites
8. Complementary/alternative therapies
   • Chinese herbs
   • Homeopathy
   • Hypnotherapy/biofeedback
   • Massage therapy

Major Outcomes Considered

• Occurrence of atopic dermatitis
• Therapeutic effectiveness as measured by clinical signs and symptoms blood cortisol levels symptom scores bacterial colonization and serum immunoglobulin E (IgE) levels
• Adverse events

Methods Used to Collect/Select Evidence

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Description of Methods used to Collect/Select the Evidence

A work group of recognized experts employed an evidence-based model and the evidence was obtained primarily from a search of MEDLINE and EMBASE databases spanning the years 1990 to June 3 2003. Search terms included atopic dermatitis and atopic eczema as keywords subject words and title words combined with treatment therapy prevention and prophylaxis. Searches were also undertaken for each specific intervention as keyword subject word and title word alone and combined with atopic dermatitis and atopic eczema. Clinical trials and other sources of information were identified in the results of these searches and in the Clinical Trials Database of the Cochrane Collaboration. Additional searches were done by hand searching publications including reviews meta-analyses and correspondence. Only English-language publications were reviewed. Statistical assistance was provided by Hayes Inc a health technology assistance assessment service. Also there was reliance on the comprehensive "Systematic Review of Treatments for Atopic Eczema" published as a Health Technology Assessment 2000 and listed in the bibliography of the original guideline.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence

Expert Consensus (Committee)
Weighting According to a Rating Scheme (Scheme Given)

Rating Scheme for the Strength of the Evidence

I: Properly designed randomized controlled trial

II-1: Well-designed controlled trial without randomization

II-2: Well-designed cohort or case-control analytic study preferably from more than one center or research group

II-3: Time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Clinical experience descriptive studies or reports of expert committees.

Methods Used to Analyze the Evidence

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Description of the Methods Used to Analyze the Evidence

The available evidence was evaluated using a method described by Goodman CS. National Information Center on Health Services Research & Health Care Technology (NICHSR) [Web site]. TA101 Introduction to Health Care Technology Assessment. January 1998. Available at: http://www.nlm.nih.gov/archive//20040831/nichsr/ta101/ta101_c1.html.

Methods Used to Formulate the Recommendations

Expert Consensus

Description of Methods Used to Formulate the Recommendations

Every attempt was made to present a balanced approach to clinical recommendations; however high quality randomized clinical trials were often found lacking for the scope of the guideline. In these cases consensus of expert opinion was used with a grading of evidence to assist the reader in evaluating the recommendations.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

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

Method of Guideline Validation

External Peer Review
Internal Peer Review

Description of Method of Guideline Validation

In accordance with the revised 2002 administrative regulations the final draft was submitted to the 2nd Expert Review Team. This team consisted of 3 to 5 recognized experts that were given a copy of the draft and had 30 days to comment.

The document was then submitted to the Guidelines/Outcomes Task Force and the work group for their approval and if necessary further revision. The guideline was then sent to the members of the Board of Directors for a 30-day comment period. Board member comments were reviewed and acted upon by the Committee in consultation with the Task Force.

The draft guideline was then published as a draft and mailed to the entire American Academy of Dermatology membership for a 30-day comment period. In consultation with the Task Force Chairs the Committee acted upon all comments received. The Committee approved the final draft and submitted it to the Board of Directors for final Board approval on July 26 2003.

Major Recommendations

Level of evidence grades (I-III) are defined at the end of the "Major Recommendations" field.

1. Prevention Measures During Pregnancy and After Birth
   • During pregnancy there can be no global recommendations regarding dietary interventions and aeroallergen avoidance for the mother; there is no conclusive evidence that manipulation prevents atopic dermatitis (AD) either in the infant or child.
   • Despite numerous studies there has been no definitive evidence that exclusive breast feeding aeroallergen avoidance and/or early introduction of solid foods influences the development of AD. There is suggestive evidence that prolonged breast feeding may delay the onset of AD.
   • Probiotic treatment during pregnancy and nursing may delay the onset of AD in infants and children (Kalliomaki et al. 2001; Rautava Kalliomaki & Isolauri 2002; Rosenfeldt et al. 2003; Saarinen & Kajosaari 1995).

Recommendation	Consensus of Opinion	Level of Evidence	Reference Numbers
Role of dietary intervention	Unanimous expert opinion	I-II-2	Chandra & Hamed 1991; Halken et al. 1992; Marini et al. 1996; Odelram et al. 1996; Zeiger & Heller 1995
Role of aeroallergen avoidance for the mother	Unanimous expert opinion	I	Odelram et al. 1996; Zeiger & Heller 1995
Role of prolonged breast feeding	Unanimous expert opinion	II-2	Chandra & Hamed 1991; Halken et al. 1992; Bergmann et al. 2002
Role of probiotics	Unanimous expert opinion	I	Kalliomaki et al. 2001; Rautava Kalliomaki & Isolauri 2002; Rosenfeldt et al. 2003; Saarinen & Kajosaari 1995

 

2. Topical Corticosteroids
   • Topical corticosteroids are the standard of care to which other treatments are compared.
   • Cutaneous complications such as striae atrophy and telangiectasia limit the long-term use of these agents.
   • Despite the extensive use of topical corticosteroids there are limited data regarding optimal corticosteroid concentrations duration and frequency of therapy and quantity of application; similarly data supporting the perception that long term corticosteroid use is not associated with extracutaneous adverse effects are lacking.
   • Altering the local environment by hydration and/or occlusion as well as varying the vehicle can impact the absorption and effect of the topical corticosteroid steroid administered.
   • Tachyphylaxis is a clinical concern but there is no experimental documentation.
   • The use of long-term intermittent application of corticosteroids appears helpful and safe in two randomized controlled studies (Van Der Meer et al. 1999; Hanifi Gupta & Rajagopalan 2002). Independent studies of other formulations are needed.

Recommendation	Consensus of Opinion	Level of Evidence	Reference Numbers
Use of topical corticosteroids	Unanimous expert opinion	II-1 & III	Ainley-Walker Patel & David 1998; Friedlander Hebert & Allen 2002
Possible cutaneous complications	Unanimous expert opinion	I & III	Charman Morris & Williams 2000; Hoare Li Wan Po & Williams 2000 (Appendix 3); Kelly et al. 1994
Duration of therapy frequency of application and quantity of application uncertain	Unanimous expert opinion	I-III	Lebwohl 1999; Van Der Meer et al. 1999; Long Mills & Finlay 1998
Effects of hydration/occlusion	Unanimous expert opinion	I & III	Van Der Meer et al. 1999; Wolkerstorfer et al. 2000; Bleehen et al. 1995; Tharp 1996
Possible development of tachyphylaxis	Unanimous expert opinion	No studies	No studies
Role of long-term intermittent application of corticosteroids	Unanimous expert opinion	I	Van Der Meer et al. 1999; Thomas et al. 2002; Hanifin Gupta & Rajagopalan 2002

 

3. Other Topical Therapies
   • Emollients are a standard of care steroid sparing and useful for both prevention and maintenance therapy.
   • Calcineurin inhibitors pimecrolimus and tacrolimus have been shown to reduce the extent severity and symptoms of AD in adults and children.
   • Tar may be associated with therapeutic benefits but is limited by compliance.
   • Short-term adjunctive use of topical doxepin may aid in the reduction of pruritus but the development of side effects may limit usefulness.

Recommendations	Consensus of Opinion	Level of Evidence	Reference Number
Use of emollients	Unanimous expert opinion	I	Hanifin et al. 1998
Use of pimecrolimus*	Unanimous expert opinion	I	Ho et al. 2003; Kapp et al. 2002; Meurer et al. 2002; Wahn et al. 2002
Use of tacrolimus*	Unanimous expert opinion	I	Ruzicka et al. 1997; Boguniewicz et al. 1998; Paller et al. 2001; Reitamo et al. "Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone acetate" 2002; Reitamo et al. "Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone butyrate" 2002
Use of tar	Unanimous expert opinion	II-2	Berberian et al. 1999
Short-term use of doxepin	Unanimous expert opinion	I	Drake Fallon & Sober 1994; Berberian et al. 1999

 

4. Antibiotics and Antiseptics
   • Patients with AD are commonly colonized with Staphylococcus aureus.
   • Antibiotics both systemic and topical temporarily reduce S. aureus colonization on skin.
   • Without signs of infection oral antibiotics generally have a minimal therapeutic effect on the dermatitis.
   • Oral antibiotics can be highly beneficial when skin infection is present.
   • Topical antibiotics can be effective when infection is present; however development of resistance is a concern.

Recommendation	Consensus of Opinion	Level of Evidence	References
Staph colonization of the skin	Unanimous expert opinion	I	Leyden Marples & Klingman 1974
Role of systemic antibiotics	Unanimous expert opinion	I	Leung 2002
Role of topical antibiotics	Unanimous expert opinion	I	Ainley-Walker Patel & David 1998

 

5. Oral Antihistamines
   • There is little evidence that sedating or nonsedating antihistamines are effective in relieving itch or urticarial symptoms associated with AD
   • For patients with significant sleep disruption due to itch allergic dermatographism or allergic rhinoconjunctivitis sedating antihistamines may be useful. Many patients with AD also have accompanying allergic rhinoconjunctivitis urticaria and dermatographism and therefore may be benefited by the use of antihistamines.

Recommendation	Consensus of Opinion	Level of Evidence	References
Role of sedative antihistamines	Unanimous expert opinion	I	Wahlgren Hagermark & Bergstrom 1990; Monroe 1992
Role of nonsedating antihistamines	Unanimous expert opinion	I	Wahlgren Hagermark & Bergstrom 1990; Monroe 1992

 

6. Dietary Restrictions in Established Atopic Dermatitis
   • Dietary restriction of eggs may be beneficial in infants with immunoglobulin E (IgE) reactivity to egg but there is no evidence that other restrictions in diet are of therapeutic value for established AD.
   • There is no evidence that fish oil borage oil evening primrose oil or vitamin or mineral supplements have therapeutic value in AD.
   • Immediate type hypersensitivity reactions such as urticaria are common in this population and may be mistaken for AD.

Recommendation	Consensus of Opinion	Level of Evidence	References
Role of dietary egg restriction	Unanimous opinion	I-III	Sloper Wadsworth & Brostoff 1991; Lever et al. 1998; Mabin Sykes & David 1995
Role of vitamin and mineral supplements and evening primrose oil	Unanimous opinion	I	Berth-Jones & Graham-Brown 1993; Hederos & Berg 1996; Giménez-Arnau et al. 1997; Henz et al. 1999

 

7. Non-Pharmacological Interventions
   • Psychotherapeutic approaches to the treatment of AD are supported for a combination of educational and psychological interventions.
   • Ultraviolet (UV) phototherapy including combination broad-band UVB/UVA narrow band UVB therapy chemophototherapy using methoxypsoralen (PUVA) and UVA1 (wavelength 340 to 400 nm) is well established in the treatment of AD although relapse following cessation of therapy frequently occurs.
   • It is unclear if house dust mite strategies are effective for most patients with AD.

Recommendation	Consensus of Opinion	Level of Evidence	References
Role of psychotherapeutic approaches	Unanimous opinion	III	Cole Roth & Sachs 1988; Horne White & Varigos 1989; Ehlers Stangier & Gieler 1995
Role of broad-band UVB & UVA	Unanimous opinion	I	Reynolds et al. 2001
Role of narrow-band UVB	Unanimous opinion	I-III	George et al. 1993; Grundmann-Kollmann et al. 1999; Collins & Ferguson 1995; Hudson-Peacock Diffey & Farr 1996; Reynolds et al. 2001
Role of PUVA	Unanimous opinion	II-2-III	Jekler & Larkö 1991; George et al. 1993; Grundmann-Kollmann et al. 1999; Morris & Saihan 2002
Role of UVA1	Unanimous opinion	I	Krutmann et al. 1998
Role of house dust mite allergen reduction	Unanimous opinion	I	Tan et al. 1996; Ricci et al. 2000; Holm et al. 2001

 

8. Systemic Immunomodulary Agents
   • Cyclosporin is effective in the treatment of severe AD but its usefulness may be limited by side effects.
   • Interferon gamma may be effective but the evidence is limited in a subset of patients.
   • Systemic corticosteroids are known to be effective in the short-term treatment of AD but no evidence exists to support their use and rebound flaring and long-term side effects are limiting.
   • Conflicting data exist about the efficacy of azathioprine mycophenolate mofetil and intravenous immunoglobulin (IVIg).
   • There is insufficient evidence to support the role of leukotriene inhibitors thymopentin (TP-5) allergen-antibody complexes of house dust mites desensitization injections theophylline and papaverine in the treatment of AD.

Recommendation	Consensus of Opinion	Level of Evidence	References
Role of cyclosporin A	Unanimous opinion	I	Sowden et al. 1991
Role of recombinant human interferon-gamma	Unanimous opinion	I	Hanifin et al. 1993; Stevens et al. 1998; Jang et al. 2000
Role of systemic corticosteroids	Unanimous opinion	III	Sidbury & Hanifin 2000
Role of mycophenolate mofetil IVIg and azathioprine	Unanimous opinion	II-2-III	Wakim et al. 1998; Noh & Lozano 2001; Meggitt & Reynolds 2001; Berth-Jones et al. 2002; Neuber et al. 2000; Grundmann-Kollmann et al. 2001

 

9. Complementary/Alternative Therapies
   • There is conflicting evidence regarding efficacy and potential concerns regarding hepatic and other toxicities of Chinese herbal therapy for AD.
   • Peer-reviewed clinical studies of the value of homeopathy in the treatment of AD have not been reported. To date there is no evidence in the literature to support its use in the treatment of AD.
   • More clinical research is needed to adequately assess the role of hypnotherapy acupuncture massage therapy and biofeedback therapy in the treatment of AD although preliminary results are encouraging.

   Recommendation	Consensus of Opinion	Level of Evidence	References
   Role of Chinese herbal therapy	Unanimous opinion	I	Sheehan et al. 1992; Sheehan & Atherton 1992; Fung et al. 1999

Definitions:

Levels of Evidence

I: Properly designed randomized controlled trial

II-1: Well-designed controlled trial without randomization

II-2: Well-designed cohort or case-control analytic study preferably from more than one center or research group

II-3: Time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Clinical experience descriptive studies or reports of expert committees

Clinical Algorithm(s)

None provided

References Supporting the Recommendations

• Ainley-Walker PF Patel L David TJ. Side to side comparison of topical treatment in atopic dermatitis. Arch Dis Child 1998 Aug;79(2):149-52. PubMed



• Berberian BJ Breneman DL Drake LA Gratton D Raimir SS Phillips S Sulica VI Bernstein JE. The addition of topical doxepin to corticosteroid therapy: an improved treatment regimen for atopic dermatitis. Int J Dermatol 1999 Feb;38(2):145-8. PubMed



• Bergmann RL Diepgen TL Kuss O Bergmann KE Kujat J Dudenhausen JW Wahn U. Breastfeeding duration is a risk factor for atopic eczema. Clin Exp Allergy 2002 Feb;32(2):205-9. PubMed



• Berth-Jones J Graham-Brown RA. Placebo-controlled trial of essential fatty acid supplementation in atopic dermatitis. Lancet 1993 Jun 19;341(8860):1557-60. PubMed



• Berth-Jones J Takwale A Tan E Barclay G Agarwal S Ahmed I Hotchkiss K Graham-Brown RA. Azathioprine in severe adult atopic dermatitis: a double-blind placebo-controlled crossover trial. Br J Dermatol 2002 Aug;147(2):324-30. PubMed



• Bleehen SS Chu AC Hamann I Holden C Hunter JA Marks R. Fluticasone propionate 0.05% cream in the treatment of atopic eczema: a multicentre study comparing once-daily treatment and once-daily vehicle cream application versus twice-daily treatment. Br J Dermatol 1995 Oct;133(4):592-7. PubMed



• Boguniewicz M Fiedler VC Raimer S Lawrence ID Leung DY Hanifin JM. A randomized vehicle-controlled trial of tacrolimus ointment for treatment of atopic dermatitis in children. Pediatric Tacrolimus Study Group. J Allergy Clin Immunol 1998 Oct;102(4 Pt 1):637-44. PubMed



• Chandra RK Hamed A. Cumulative incidence of atopic disorders in high risk infants fed whey hydrolysate soy and conventional cow milk formulas. Ann Allergy 1991 Aug;67(2 Pt 1):129-32. PubMed



• Charman CR Morris AD Williams HC. Topical corticosteroid phobia in patients with atopic eczema. Br J Dermatol 2000 May;142(5):931-6. PubMed



• Cole WC Roth HL Sachs LB. Group psychotherapy as an aid in the medical treatment of eczema. J Am Acad Dermatol 1988 Feb;18(2 Pt 1):286-91. PubMed



• Collins P Ferguson J. Narrowband (TL-01) UVB air-conditioned phototherapy for atopic eczema in children. Br J Dermatol 1995 Oct;133(4):653-5. PubMed



• Drake LA Fallon JD Sober A. Relief of pruritus in patients with atopic dermatitis after treatment with topical doxepin cream. The Doxepin Study Group. J Am Acad Dermatol 1994 Oct;31(4):613-6. PubMed



• Ehlers A Stangier U Gieler U. Treatment of atopic dermatitis: a comparison of psychological and dermatological approaches to relapse prevention. J Consult Clin Psychol 1995 Aug;63(4):624-35. PubMed



• Friedlander SF Hebert AA Allen DB. Safety of fluticasone propionate cream 0.05% for the treatment of severe and extensive atopic dermatitis in children as young as 3 months. J Am Acad Dermatol 2002 Mar;46(3):387-93. PubMed



• Fung AY Look PC Chong LY But PP Wong E. A controlled trial of traditional Chinese herbal medicine in Chinese patients with recalcitrant atopic dermatitis. Int J Dermatol 1999 May;38(5):387-92. PubMed



• George SA Bilsland DJ Johnson BE Ferguson J. Narrow-band (TL-01) UVB air-conditioned phototherapy for chronic severe adult atopic dermatitis. Br J Dermatol 1993 Jan;128(1):49-56. PubMed



• Gimenez-Arnau A Barranco C Alberola M Wale C Serrano S Buchanan MR Camarasa JG. Effects of linoleic acid supplements on atopic dermatitis. Adv Exp Med Biol 1997;433:285-9. PubMed



• Grundmann-Kollmann M Behrens S Podda M Peter RU Kaufmann R Kerscher M. Phototherapy for atopic eczema with narrow-band UVB. J Am Acad Dermatol 1999 Jun;40(6 Pt 1):995-7. PubMed



• Grundmann-Kollmann M Podda M Ochsendorf F Boehncke WH Kaufmann R Zollner TM. Mycophenolate mofetil is effective in the treatment of atopic dermatitis. Arch Dermatol 2001 Jul;137(7):870-3. PubMed



• Halken S Host A Hansen LG Osterballe O. Effect of an allergy prevention programme on incidence of atopic symptoms in infancy. A prospective study of 159 "high-risk" infants. Allergy 1992 Oct;47(5):545-53. PubMed



• Hanifin J Gupta AK Rajagopalan R. Intermittent dosing of fluticasone propionate cream for reducing the risk of relapse in atopic dermatitis patients. Br J Dermatol 2002 Sep;147(3):528-37. PubMed



• Hanifin JM Hebert AA Mays SR et al. Effects of a low-potency corticosteroid lotion plus a moisturizing regimen in the treatment of atopic dermatitis. Curr Ther Res Clin Exp 1998;59(4):227-33.



• Hanifin JM Schneider LC Leung DY Ellis CN Jaffe HS Izu AE Bucalo LR Hirabayashi SE Tofte SJ Cantu-Gonzales G et al.. Recombinant interferon gamma therapy for atopic dermatitis. J Am Acad Dermatol 1993 Feb;28(2 Pt 1):189-97. PubMed



• Hederos CA Berg A. Epogam evening primrose oil treatment in atopic dermatitis and asthma. Arch Dis Child 1996 Dec;75(6):494-7. PubMed



• Henz BM Jablonska S van de Kerkhof PC Stingl G Blaszczyk M Vandervalk PG Veenhuizen R Muggli R Raederstorff D. Double-blind multicentre analysis of the efficacy of borage oil in patients with atopic eczema. Br J Dermatol 1999 Apr;140(4):685-8. PubMed



• Ho VC Gupta A Kaufmann R Todd G Vanaclocha F Takaoka R Folster-Holst R Potter P Marshall K Thurston M Bush C Cherill R. Safety and efficacy of nonsteroid pimecrolimus cream 1% in the treatment of atopic dermatitis in infants. J Pediatr 2003 Feb;142(2):155-62. PubMed



• Hoare C Li Wan Po A Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess 2000;4(37):1-191. [420 references] PubMed



• Holm L Bengtsson A van Hage-Hamsten M Ohman S Scheynius A. Effectiveness of occlusive bedding in the treatment of atopic dermatitis--a placebo-controlled trial of 12 months' duration. Allergy 2001 Feb;56(2):152-8. PubMed



• Horne DJ White AE Varigos GA. A preliminary study of psychological therapy in the management of atopic eczema. Br J Med Psychol 1989 Sep;62 ( Pt 3):241-8. PubMed



• Hudson-Peacock MJ Diffey BL Farr PM. Narrow-band UVB phototherapy for severe atopic dermatitis. Br J Dermatol 1996 Aug;135(2):332. PubMed



• Jang IG Yang JK Lee HJ Yi JY Kim HO Kim CW Kim TY. Clinical improvement and immunohistochemical findings in severe atopic dermatitis treated with interferon gamma. J Am Acad Dermatol 2000 Jun;42(6):1033-40. PubMed



• Jekler J Larko O. UVA solarium versus UVB phototherapy of atopic dermatitis: a paired-comparison study. Br J Dermatol 1991 Dec;125(6):569-72. PubMed



• Kalliomaki M Salminen S Arvilommi H Kero P Koskinen P Isolauri E. Probiotics in primary prevention of atopic disease: a randomised placebo-controlled trial. Lancet 2001 Apr 7;357(9262):1076-9. PubMed



• Kapp A Papp K Bingham A Folster-Holst R Ortonne JP Potter PC Gulliver W Paul C Molloy S Barbier N Thurston M de Prost Y. Long-term management of atopic dermatitis in infants with topical pimecrolimus a nonsteroid anti-inflammatory drug. J Allergy Clin Immunol 2002 Aug;110(2):277-84. PubMed



• Kelly JW Cains GD Rallings M Gilmore SJ. Safety and efficacy of monetasone furoate cream in the treatment of steroid responsive dermatoses. Aust J Dermatol 1994;32:85-91.



• Krutmann J Diepgen TL Luger TA Grabbe S Meffert H Sonnichsen N Czech W Kapp A Stege H Grewe M Schopf E. High-dose UVA1 therapy for atopic dermatitis: results of a multicenter trial. J Am Acad Dermatol 1998 Apr;38(4):589-93. PubMed



• Lebwohl M. A comparison of once-daily application of mometasone furoate 0.1% cream compared with twice-daily hydrocortisone valerate 0.2% cream in pediatric atopic dermatitis patients who failed to respond to hydrocortisone: mometasone furoate study group. Int J Dermatol 1999 Aug;38(8):604-6. PubMed



• Leung DYM. Role of staphylococcus aureus in atopic dermatitis. In: Bieber T Leung DYM editor(s). New York (NY): Marcel Dekker; 2002. p. 401-18.



• Lever R MacDonald C Waugh P Aitchison T. Randomised controlled trial of advice on an egg exclusion diet in young children with atopic eczema and sensitivity to eggs. Pediatr Allergy Immunol 1998 Feb;9(1):13-9. PubMed



• Leyden JJ Marples RR Kligman AM. Staphylococcus aureus in the lesions of atopic dermatitis. Br J Dermatol 1974 May;90(5):525-30. PubMed



• Long CC Mills CM Finlay AY. A practical guide to topical therapy in children. Br J Dermatol 1998 Feb;138(2):293-6. PubMed



• Mabin DC Sykes AE David TJ. Controlled trial of a few foods diet in severe atopic dermatitis. Arch Dis Child 1995 Sep;73(3):202-7. PubMed



• Marini A Agosti M Motta G Mosca F. Effects of a dietary and environmental prevention programme on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up. Acta Paediatr Suppl 1996 May;414:1-21. PubMed



• Meggitt SJ Reynolds NJ. Azathioprine for atopic dermatitis. Clin Exp Dermatol 2001 Jul;26(5):369-75. [39 references] PubMed



• Meurer M Folster-Holst R Wozel G Weidinger G Junger M Brautigam M. Pimecrolimus cream in the long-term management of atopic dermatitis in adults: a six-month study. Dermatology 2002;205(3):271-7. PubMed



• Monroe EW. Relative efficacy and safety of loratadine hydroxyzine and placebo in chronic idiopathic urticaria and atopic dermatitis. Clin Ther 1992 Jan-Feb;14(1):17-21. PubMed



• Morris AD Saihan EM. Maintenance psoralen plus ultraviolet A therapy: does it have a role in the treatment of severe atopic eczema. Br J Dermatol 2002 Apr;146(4):705-7. PubMed



• Neuber K Schwartz I Itschert G Dieck AT. Treatment of atopic eczema with oral mycophenolate mofetil. Br J Dermatol 2000 Aug;143(2):385-91. PubMed



• Noh G Lozano F. Intravenous immune globulin effects on serum-soluble CD5 levels in atopic dermatitis. Clin Exp Allergy 2001 Dec;31(12):1932-8. PubMed



• Odelram H Vanto T Jacobsen L Kjellman NI. Whey hydrolysate compared with cow's milk-based formula for weaning at about 6 months of age in high allergy-risk infants: effects on atopic disease and sensitization. Allergy 1996 Mar;51(3):192-5. PubMed



• Paller A Eichenfield LF Leung DY Stewart D Appell M. A 12-week study of tacrolimus ointment for the treatment of atopic dermatitis in pediatric patients. J Am Acad Dermatol 2001 Jan;44(1 Suppl):S47-57. PubMed



• Rautava S Kalliomaki M Isolauri E. Probiotics during pregnancy and breast-feeding might confer immunomodulatory protection against atopic disease in the infant. J Allergy Clin Immunol 2002 Jan;109(1):119-21. PubMed



• Reitamo S Rustin M Ruzicka T Cambazard F Kalimo K Friedmann PS Schoepf E Lahfa M Diepgen TL Judodihardjo H Wollenberg A Berth-Jones J Bieber T. Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone butyrate ointment in adult patients with atopic dermatitis. J Allergy Clin Immunol 2002 Mar;109(3):547-55. PubMed



• Reitamo S Van Leent EJ Ho V Harper J Ruzicka T Kalimo K Cambazard F Rustin M Taieb A Gratton D Sauder D Sharpe G Smith C Junger M de Prost Y. Efficacy and safety of tacrolimus ointment compared with that of hydrocortisone acetate ointment in children with atopic dermatitis. J Allergy Clin Immunol 2002 Mar;109(3):539-46. PubMed



• Reynolds NJ Franklin V Gray JC Diffey BL Farr PM. Narrow-band ultraviolet B and broad-band ultraviolet A phototherapy in adult atopic eczema: a randomised controlled trial. Lancet 2001 Jun 23;357(9273):2012-6. PubMed



• Ricci G Patrizi A Specchia F Menna L Bottau P D'Angelo V Masi M. Effect of house dust mite avoidance measures in children with atopic dermatitis. Br J Dermatol 2000 Aug;143(2):379-84. PubMed



• Rosenfeldt V Benfeldt E Nielsen SD Michaelsen KF Jeppesen DL Valerius NH Paerregaard A. Effect of probiotic Lactobacillus strains in children with atopic dermatitis. J Allergy Clin Immunol 2003 Feb;111(2):389-95. PubMed



• Ruzicka T Bieber T Schopf E Rubins A Dobozy A Bos JD Jablonska S Ahmed I Thestrup-Pedersen K Daniel F Finzi A Reitamo S. A short-term trial of tacrolimus ointment for atopic dermatitis. European Tacrolimus Multicenter Atopic Dermatitis Study Group. N Engl J Med 1997 Sep 18;337(12):816-21. PubMed



• Saarinen UM Kajosaari M. Breastfeeding as prophylaxis against atopic disease: prospective follow-up study until 17 years old. Lancet 1995 Oct 21;346(8982):1065-9. PubMed



• Sheehan MP Atherton DJ. A controlled trial of traditional Chinese medicinal plants in widespread non-exudative atopic eczema. Br J Dermatol 1992 Feb;126(2):179-84. PubMed



• Sheehan MP Rustin MH Atherton DJ Buckley C Harris DW Brostoff J Ostlere L Dawson A Harris DJ. Efficacy of traditional Chinese herbal therapy in adult atopic dermatitis. Lancet 1992 Jul 4;340(8810):13-7. PubMed



• Sidbury R Hanifin JM. Systemic therapy of atopic dermatitis. Clin Exp Dermatol 2000 Oct;25(7):559-66. [58 references] PubMed



• Sloper KS Wadsworth J Brostoff J. Children with atopic eczema. I: Clinical response to food elimination and subsequent double-blind food challenge. Q J Med 1991 Aug;80(292):677-93. PubMed



• Sowden JM Berth-Jones J Ross JS Motley RJ Marks R Finlay AY Salek MS Graham-Brown RA Allen BR Camp RD. Double-blind controlled crossover study of cyclosporin in adults with severe refractory atopic dermatitis. Lancet 1991 Jul 20;338(8760):137-40. PubMed



• Stevens SR Hanifin JM Hamilton T Tofte SJ Cooper KD. Long-term effectiveness and safety of recombinant human interferon gamma therapy for atopic dermatitis despite unchanged serum IgE levels. Arch Dermatol 1998 Jul;134(7):799-804. PubMed



• Tan BB Weald D Strickland I Friedmann PS. Double-blind controlled trial of effect of housedust-mite allergen avoidance on atopic dermatitis. Lancet 1996 Jan 6;347(8993):15-8. PubMed



• Tharp MD. A comparison of twice-daily and once-daily administration of fluticasone propionate cream 0.05% in the treatment of eczema. Cutis 1996 Feb;57(2 Suppl):19-26. PubMed



• Thomas KS Armstrong S Avery A Po AL O'Neill C Young S Williams HC. Randomised controlled trial of short bursts of a potent topical corticosteroid versus prolonged use of a mild preparation for children with mild or moderate atopic eczema. BMJ 2002 Mar 30;324(7340):768. PubMed



• Van Der Meer JB Glazenburg EJ Mulder PG Eggink HF Coenraads PJ. The management of moderate to severe atopic dermatitis in adults with topical fluticasone propionate. The Netherlands Adult Atopic Dermatitis Study Group. Br J Dermatol 1999 Jun;140(6):1114-21. PubMed



• Wahlgren CF Hagermark O Bergstrom R. The antipruritic effect of a sedative and a non-sedative antihistamine in atopic dermatitis. Br J Dermatol 1990 Apr;122(4):545-51. PubMed



• Wahn U Bos JD Goodfield M Caputo R Papp K Manjra A Dobozy A Paul C Molloy S Hultsch T Graeber M Cherill R de Prost Y. Efficacy and safety of pimecrolimus cream in the long-term management of atopic dermatitis in children. Pediatrics 2002 Jul;110(1 Pt 1):e2. PubMed



• Wakim M Alazard M Yajima A Speights D Saxon A Stiehm ER. High dose intravenous immunoglobulin in atopic dermatitis and hyper-IgE syndrome. Ann Allergy Asthma Immunol 1998 Aug;81(2):153-8. PubMed



• Wolkerstorfer A Visser RL De Waard van der Spek FB Mulder PG Oranje AP. Efficacy and safety of wet-wrap dressings in children with severe atopic dermatitis: influence of corticosteroid dilution. Br J Dermatol 2000 Nov;143(5):999-1004. PubMed



• Zeiger RS Heller S. The development and prediction of atopy in high-risk children: follow-up at age seven years in a prospective randomized study of combined maternal and infant food allergen avoidance. J Allergy Clin Immunol 1995 Jun;95(6):1179-90. PubMed

Type of Evidence supporting the Recommendations

The type of supporting evidence is stated for each intervention. Refer to the "Major Recommendations" field.

Potential Benefits

Appropriate treatment and management of patients with AD or atopic eczema

Potential Harms

Theoretical concerns and side effects reported in clinical trials are discussed in the original guideline document.

Qualifying Statements

• Adherence to these guidelines will not ensure successful treatment in every situation. Furthermore these guidelines should not be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances presented by the individual patient.
• This report reflects the best available data at the time the report was prepared but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools

Patient Resources

For information about availability see the "Availability of Companion Documents" and "Patient Resources" fields below.

IOM Care Need

Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• Hanifin JM Cooper KD Ho VC Kang S Krafchik BR Margolis DJ Schachner LA Sidbury R Whitmore SE Sieck CK Van Voorhees AS. Guidelines of care for atopic dermatitis. J Am Acad Dermatol 2004 Mar;50(3):391-404. [212 references] PubMed

Adaptation

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

Source(s) of Funding

American Academy of Dermatology operational funds and member volunteer time supported the development of this guideline.

Guideline Committee

American Academy of Dermatology Work Group
American Academy of Dermatology Guidelines/Outcomes Task Force

Composition of Group that Authored the Guideline

Work Group Members: Jon M. Hanifin MD (Chair Work Group); Kevin D. Cooper MD; Vincent C. Ho MD; Sewon Kang MD; Bernice R. Krafchik MD; David J. Margolis MD; Lawrence A. Schachner MD; Robert Sidbury MD; Susan E. Whitmore MD; Carol K. Sieck RN MSN; Abby S. Van Voorhees MD (Chair Guidelines/Outcomes Task Force)

Guidelines/Outcomes Task Force Members: Abby S. Van Voorhees MD (Chair Task Force); Mark A. Bechtel MD; Boni E. Elewski MD; Steven R. Feldman MD; Cindy Francyn Hoffman MD; Robert S. Kirsner MD; Lawrence M. Lieblich MD; David J. Margolis MD; Yves P. Poulin MD; Barbara R. Reed MD; Dirk B. Robertson MD; Erin W. Warshaw MD; Daniel A. Smith MD; Carol K. Sieck RN MSN

Financial Disclosures/Conflicts of Interest

Each of the following Work Group Members have served as a consultant received research support or clinical research grants from the following companies:

Jon M. Hanifin MD Chair Atopic Dermatitis Work Group: 3M Admirall Allergan Berlex Cellergy Connetics Corixa Fujisawa Glaxo Smith Kline Leo Ligand Novartis P & G Stiefel Taisko

Abby S. Van Voorhees MD Chair Guidelines/Outcomes Task Force: Allergan Amgen Biogen Boehringer/Ingelhein Genentech Glaxo Smith Kline IDEC Merck

Kevin D. Cooper MD: Biogen Centocor Genmab Glaxo Smith Kline Fujisawa Proctor & Gamble/Estee Lauder/L'Oreal

Vincent C. Ho MD: Fujisawa Leo Biogen Novartis Allergan Abbott

Sewon Kang MD: Fujisawa Novartis

Bernice R. Krafchik MD: Fujisawa Canada Novartis Canada

David J. Margolis MD: Novartis

Lawrence A. Schachner MD: Ferndell Laboratory Fujisawa Novartis

Robert Sidbury MD: Connetics Novartis

Susan E. Whitmore MD: None

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Academy of Dermatology Association Web site.

Print copies: Available from the AAD PO Box 4014 Schaumburg IL 60168-4014 Phone: (847) 330-0230 ext. 333; Fax: (847) 330-1120; Web site: www.aad.org.

Availability of Companion Documents

The following is available:

• Guidelines of care for atopic dermatitis. Technical report. Schaumburg (IL): American Academy of Dermatology (AAD) 2003.

Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Dermatology Association Web site.

Print copies: Available from the AAD PO Box 4014 Schaumburg IL 60168-4014 Phone: (847) 330-0230 ext. 333; Fax: (847) 330-1120; Web site: www.aad.org.

Patient Resources

The following is available:

• Eczema/atopic dermatitis. American Academy of Dermatology; Schaumburg (IL): 1995.

Electronic copies: Available from the American Academy of Dermatology Web site.

Print copies: Available from the AAD PO Box 4014 Schaumburg IL 60168-4014 Phone: (847) 330-0230 ext. 333; Fax: (847) 330-1120; Web site: www.aad.org.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS

This NGC summary was completed by ECRI on April 19 2004. The information was verified by the guideline developer on May 19 2004. This summary was updated by ECRI on March 15 2005 following release of a public health advisory from the U.S. Food and Drug Administration regarding the use of Elidel. 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). This summary was updated by ECRI Institute on February 19 2009 following the U.S. Food and Drug Administration (FDA) advisory on CellCept (mycophenolate mofetil).

COPYRIGHT STATEMENT

The American Academy of Dermatology Association places no restriction on the downloading use or reproduction of "Guidelines of Care for Atopic Dermatitis."

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop produce approve or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies relevant professional associations public or private organizations other government agencies health care organizations or plans and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC AHRQ and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC AHRQ or its contractor ECRI Institute and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.