Translating Atopic Dermatitis

Management Guidelines Into Practice

for Primary Care Providers
Lawrence F. Eichenfield, MDa, Mark Boguniewicz, MDb, Eric L. Simpson, MDc, John J. Russell, MDd, Julie K. Block, BAe,
Steven R. Feldman, MD, PhDf,g, Adele R. Clark, PA-Cf, Susan Tofte, BSN, MS, FNP-Ch, Jeffrey D. Dunn, PharmD, MBAi,
Amy S. Paller, MD, MSj

Atopic dermatitis affects a substantial number of children, many of whom seek abstract
initial treatment from their pediatrician or other primary care provider.
Approximately two-thirds of these patients have mild disease and can be
adequately managed at the primary care level. However, recent treatment
guidelines are written primarily for use by specialists and lack certain
elements that would make them more useful to primary care providers. This
article evaluates these recent treatment guidelines in terms of evaluation
criteria, treatment recommendations, usability, accessibility, and applicability
to nonspecialists and integrates them with clinical evidence to present
a streamlined severity-based treatment model for the management of
a majority of atopic dermatitis cases. Because each patient’s situation is a
Departments of Pediatrics and Dermatology, School of
unique, individualization of treatment plans is critical as is efficient Medicine, University of California, San Diego, San Diego,
communication and implementation of the plan with patients and caregivers. California; bDivision of Pediatric Allergy-Immunology,
Department of Pediatrics, National Jewish Health and School of
Specifically, practical suggestions for individualizing, optimizing, Medicine, University of Colorado Denver, Colorado;
implementing, and communicating treatment plans such as choosing c
Departments of Dermatology, and hNursing, Oregon Health &
Science University, Portland, Oregon; dDepartment of Family
a moisturizer formulation, avoiding common triggers, educating patients/ and Community Medicine, Sydney Kimmel Medical College,
caregivers, providing written treatment plans, and scheduling physician Thomas Jefferson University, Philadelphia, Pennsylvania;
e
National Eczema Association, San Rafael, California;
follow-up are provided along with a discussion of available resources for f
Department of Dermatology, gPathology, and Public Health
patients/caregivers and providers. Sciences, Wake Forest Baptist Health, Winston-Salem, North
Carolina; iVRx, Salt Lake City, Utah; and jDepartments of
Dermatology and Pediatrics, Feinberg School of Medicine,
Northwestern University, Chicago, Illinois
In 2009–2011, atopic dermatitis (AD) patient/caregiver education, and as the
was estimated to affect 12.5% of first-line contact for flares and issues, Dr Eichenfield determined the agenda and faculty, served
children (0–17 years of age) in the such as secondary staphylococcal as co-chair, contributed substantially to the roundtable
infection. meeting, directed development of the manuscript text and
United States, an increase of just over
graphical content, and critically reviewed each draft;
5% since 1997–1999.1 Among these On September 6, 2013, a roundtable Drs Boguniewicz, Simpson, Russell, Feldman, and Dunn,
patients, the vast majority (∼67%) are was convened to discuss challenges in and Ms Block, Ms Clark, and Ms Tofte contributed
reported to have mild disease2 and as AD management along with substantially to the roundtable meeting and critically
such may be adequately managed by reviewed each draft of the manuscript; Dr Paller served
opportunities to improve it across as co-chair, contributed substantially to the roundtable
their pediatrician or other primary care a variety of disciplines. This roundtable meeting, directed development of the manuscript text and
provider (PCP). However, the majority was unique in that it included a patient graphical content, and critically reviewed each draft; and
of pediatricians refer even their mild advocate, as well as representatives all authors approved the final manuscript as submitted.
patients to dermatologists (∼85%) and from dermatology (general and The content of this article is based on the proceedings
provide only initial, limited care pediatric), pediatric of a roundtable meeting attended by each of the
(81%).3 Whether or not patients are allergy–immunology, family medicine, authors, held September 6, 2013, in Chicago, IL, and
sponsored by Valeant Pharmaceuticals North America,
referred to dermatology, pediatricians managed care, and nursing. During the LLC (Bridgewater, NJ).
and family practitioners continue to discussion, it became clear that current
www.pediatrics.org/cgi/doi/10.1542/peds.2014-3678
play a central role in patient AD management guidelines lack certain
management for regular follow-up, elements that may enhance their DOI: 10.1542/peds.2014-3678
maintenance treatment, ongoing practical utility, especially for PCPs, Accepted for publication Feb 26, 2015

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PEDIATRICS Volume 136, number 3, September 2015 STATE-OF-THE-ART REVIEW ARTICLE
including pediatricians. This article areas. The 2012 EDF Guidelines are and sometimes serous exudate. The
will (1) evaluate the utility of current unique in providing diagnostic criteria given in the AAD
guidelines, (2) present an integrated, recommendations for monthly guidelines (Table 2)14 provide a user-
PCP-specific treatment model based amounts of topical corticosteroids to friendly set of criteria that mirror
on current guidelines and clinical prescribe and how to quantify daily many more lengthy validated criteria.
evidence, (3) give practical advice on amounts of topical drug for patients. A diagnosis of AD should only be
the implementation and optimization made when other conditions have
of written, individualized treatment Integrating Guidelines With Clinical been ruled out such as irritant
plans for patients, and (4) provide Evidence contact dermatitis, psoriasis, scabies,
recommendations to improve the With so many AD management or a viral exanthem. A variety of
utility of future guidelines, all based guidelines promulgated by different scoring systems have been proposed
on the meeting’s proceedings. groups, there is potential for these to for quantifying AD severity. Mild
conflict with each other, making it disease generally involves less body
difficult for HCPs to determine which surface area, has a more remittive
RECENT AD MANAGEMENT GUIDELINES guidelines are best suited for their course, and is associated with lower
To improve utility, management patients. The consensus among intensity itch.15 Patients who can be
guidelines should contain a concise roundtable participants was that maintained with basic management
treatment algorithm that is severity- PCPs could benefit from an integrated alone most often have mild disease.
based and not rigid (ie, allows for plan that is more straightforward and Patients with moderate-to-severe
unique patient situations) with specific, accommodates the majority disease may have greater body
instructions for when to step-up or of the cases they encounter, and surface area involvement with more
step-down treatment. Diagnostic and provides guidance as to when to refer continuous course and more severe
severity evaluation criteria should be to a dermatologist or allergist/ itch.15 These patients often require
included to provide a framework for immunologist. In addition, few more maintenance therapy.
initial and ongoing evaluation. Also, guidelines contain a treatment model
guidelines should reflect and, those that do, fail to account for Basic Management
multidisciplinary input and be freely the relapsing–remitting nature of AD Regardless of disease severity, basic
and easily accessible to all health care or for the use of proactive management strategies should be
providers (HCPs), regardless of management. implemented for every patient
specialty. To address these gaps and provide diagnosed with AD (Fig 1). These
With each iteration, AD management a useful tool for pediatricians and include proper skin care (ie, skin
guidelines have improved according PCPs in managing their patients with hydration and moisturizer applied to
to these fundamentals from the 2004 AD, we propose the following all skin), antiseptic measures
American Academy of Dermatology’s diagnostic and treatment model (ie, dilute bleach baths), and trigger
(AAD) Guidelines4 and American based on the EDF 2012 Guidelines,7,8 avoidance (general avoidance of
College of Allergy, Asthma, and the ACAAI and AAAAI 2012 Practice irritants as identified for each
Immunology (ACAAI)/American Parameters,9 and the AAD 2014 patient), with acute treatment added
Academy of Allergy, Asthma, and Guidelines10–13 with published as needed for flares (ie, acute
Immunology’s (AAAAI) Practice clinical evidence as support (Fig 1). escalation in symptoms and skin
Parameters5 through the 2006 inflammation necessitating an
European Academy of Allergology Making the Diagnosis escalation in treatment and/or
and Clinical Immunology (EAACI)/ Because there is no definitive medical advice16).
AAAAI Guidelines6 to the current laboratory test, a diagnosis of AD is
2012 European Dermatology Forum made based on a combination of Acute Treatment of Flares
(EDF) Guidelines,7,8 2012 AAAAI/ clinical symptoms: pruritic dermatitis Depending on patient and provider
ACAAI Practice Parameter Update that is chronic and/or relapsing with preference, treatment of acute flares
(published in 2013),9 and 2014 AAD characteristic distribution (face, neck, may be managed with topical
Guidelines10–13 (Table 1). Of and extensor surfaces in infants and corticosteroids of varying potency
particular note, the 2012 AAAAI/ children; flexural folds in patients of (Table 3),17 and medium potency
ACAAI Practice Parameter and EDF any age). Diagnosis is often made topical corticosteroids (eg, Class
Guidelines include input from HCPs during an acute exacerbation of skin III–IV) are often used for several days
from both allergy/immunology and inflammation characterized by to a few weeks.11 Subsequent
dermatology and specify that their intensely pruritic, erythematous maintenance therapy then depends
recommendations may be useful to papules and patches accompanied by on the severity, as well as persistence
HCPs outside of those therapeutic dry skin (ie, xerosis), excoriations, of AD signs and symptoms.

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2 EICHENFIELD et al
 TABLE 1 Recent AD Management Guidelines
Methodology (Sponsoring Evaluation Criteria Treatment Recommendations Utility
Organization[s], Year)
Diagnostic Severity Algorithm? Severity-Based? Criteria to Step-Up/ Usability Applicability: Working Group Accessibility
Criteria? Evaluation? Down Treatment? Composition and/or Intended
Audience
Composite of evidence with No No No No No Treatment recommendations Free from AAD, but
references for 9 AD listed only in text not from journal
management questions Level of evidence and
(AAD, 2004)4 consensus of opinion listed

PEDIATRICS Volume 136, number 3, September 2015

separately from
recommendations
Guidelines “sunsetted” in 2009, Working group included only
but no new guidelines issued dermatologists
until 2014
Review of literature rated Yes Only for Annotated linear Yes Yes Treatment recommendations “The evaluation and management Free from AAAAI
by category of evidence severe management (with strength of of AD are…an integral part of and JTF but not
and strength of and treatment recommendation) and an allergist/immunologist’s from journal
recommendation (ACAAI model algorithm details only listed training and practice. It is also
and AAAAI, 2004)5 in text important for the PCP to
Annotations and summary understand the basis for
statements not integrated effective evaluation and
with algorithm management…”

Review of literature (EAACI Yes No Stepwise Yes (but No (and no criteria Treatment and diagnosis Working group included Free from 1 of 2
and AAAAI/PRACTALL, treatment severity for when to use recommendations listed only allergists/immunologists and journals
2006)6 model criteria not topical in text dermatologists
included) corticosteroids No level of evidence indicated
6 TCI)

Compilation of existing Committee No Yes Yes Treatment recommendations “This guideline has been Free from EDF and
European evidence- decided that (with level of evidence and prepared for physicians, GAAPP, but not
based guidelines guidelines strength of especially dermatologists, from journal
supplemented with new should strictly recommendation) only listed pediatricians, general

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literature rated by grade concentrate on in text practitioners and all
of evidence and strength therapeutic Provides guidance for monthly specialists taking care of
of recommendation (EDF, regimens and amounts of topical patients suffering from [AD]”
2012)7,8 omit sections corticosteroids (in grams)
on clinical and how to quantify topical
diagnosis therapy amounts (ie, FTU)

3
4
TABLE 1 Continued
Methodology (Sponsoring Evaluation Criteria Treatment Recommendations Utility
Organization[s], Year)
Diagnostic Severity Algorithm? Severity-Based? Criteria to Step-Up/ Usability Applicability: Working Group Accessibility
Criteria? Evaluation? Down Treatment? Composition and/or Intended
Audience
Review of literature rated Yes Only for Annotated linear Yes Yes Treatment recommendations “The evaluation and management Free from AAAAI,
by category of evidence severe management (with strength of of AD are an integral part of an JTF, and journal
and strength of and treatment recommendation) and allergist/immunologist’s (including online
recommendation model algorithm details only listed training and practice. It is also supplement)
(update of ACAAI and in text as part of online important for the PCP to
AAAAI 2004 Practice supplement understand the basis for
Parameter, 2012)9 effective evaluation and
management…”
Algorithm annotations and “Cooperation between the patient
summary statements not and/or the patient’s guardian
integrated with algorithm or guardians, the PCP, and the
allergist, dermatologist, or
both is important in the
implementation of strategies
necessary for the care of
patients with chronic AD…
Even when an AD specialist is
consulted, the PCP continues
to play an important role in
the care of patients with AD by
ensuring continuity of care.”
In addition to allergists/
immunologists, task force
included psychologist and
dermatologists

Recommendations rated by Yes No No No No Treatment and diagnosis In addition to dermatologists, Free from AAD, but
grade of evidence and recommendations listed in working group included not from journal
strength of tables patient advocate and
recommendation with Level of evidence and strength international representatives
references for 17 AD of recommendation listed (Canada and UK)
diagnosis and separately from

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management questions recommendations
(update of AAD 2004, AAD Clinical questions that are new
Guidelines, 2014)10–13 since last issuance indicated
AAAAI indicates American Academy of Allergy, Asthma and Immunology; AAD, American Academy of Dermatology; ACAAI, American College of Allergy, Asthma and Immunology; AD, atopic dermatitis; EAACI European Academy of Allergology and Clinical
Immunology; EDF, European Dermatology Forum; FTU, fingertip unit; GAAPP, Global Allergy and Asthma Patient Platform; HCP, healthcare provider; JTF, AAAAI/ACAAI Joint Task Force on Practice Parameters; PRACTALL, Practical Allergy; PCP, primary care
physician; TCI, topical calcineurin inhibitor.

EICHENFIELD et al
FIGURE 1
Proposed treatment model/eczema action plan for pediatricians and other primary care providers. aAs tolerated during flare; direct use of moisturizers
on inflamed skin may be poorly tolerated; however, bland petrolatum is often tolerated when skin is inflamed. bApproximately 0.5 cups sodium
hypochlorite per 40 gallons of water/full bathtub or 1 mL/L. TCI, topical calcineurin inhibitor

Maintenance Therapy for Mild Disease or pimecrolimus (topical calcineurin skin areas such as the face and eyes
After the initial flare has been inhibitors [TCIs]) or medium potency should be limited), and the
controlled, many patients with mild topical corticosteroids (eg, Class effectiveness and tolerability
or more episodic AD will be able to III–IV, see Table 3; except for face and observed with a particular agent.
maintain disease control with basic eyes). Tacrolimus18–21 and Furthermore, for long-term use, it is
treatment as described above: fluticasone22 have each been studied important to use the lowest potency
moisturizers, proper skin care, etc, in long-term clinical trials of 2- to topical corticosteroid that is effective
intermittently returning to acute 3-times weekly application. to minimize the risk of adverse effects
topical corticosteroid treatment as Alternatively, a patient may be (skin atrophy, telangiectasia, striae,
needed for flares. The use of prescribed once to twice daily TCI glaucoma, rebound flare, topical
moisturizers alone as maintenance (pimecrolimus or tacrolimus); clinical corticosteroid addiction/withdrawal,
therapy, without a topical trials of this scenario have also been tachyphylaxis, Cushing disease,
antiinflammatory, is usually sufficient conducted.23,24 Although it has not adrenocortical suppression,
for mild AD. Patients whose been studied, low potency topical decreased growth rate25); this is
symptoms are not well controlled corticosteroids (Class V–VII; see particularly true for sensitive skin
with basic treatment are considered Table 3), applied locally once to twice sites, such as the face, neck, and
to have moderate-to-severe disease. daily to areas prone to recurrence, is “diaper area.”11 Failure to adequately
used by many patients to maintain suppress skin inflammation not only
Maintenance Therapy for Moderate-to- disease control. The choice of TCI perpetuates discomfort but also leads
Severe Disease versus topical corticosteroids for to continued scratching and an
Patients with moderate-to-severe AD maintenance therapy depends on increased risk for infection.
may require “proactive”/maintenance patient/caregiver and provider
therapy regularly applied to normal preference, access to medications Optimizing and Individualizing
appearing skin in flare-prone areas (including formulary status and cost Treatment Plans
and/or applied at first signs or of medication), lesion location When designing a treatment plan for
symptoms of a flare with tacrolimus (topical corticosteroid use in sensitive a specific patient, a provider should

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PEDIATRICS Volume 136, number 3, September 2015 5
TABLE 2 Diagnostic Criteria
Essential Features Important Features Associated Features
Both must be present Add support to the diagnosis, observed in most Suggestive of AD, but too nonspecific to be used for
cases of AD defining or detecting AD in research or epidemiologic
studies
1. Pruritus 1. Early age of onset 1. Atypical vascular responses (eg, facial pallor, white
dermographism, delayed blanch response)
2. Eczema (acute, subacute, chronic) 2. Atopy 2. Keratosis pilaris/pityriasis alba/hyperlinear palms/
ichthyosis
a. Typical morphology and age-specific a. Personal and/or family history 3. Ocular/periorbital changes
patterns 4. Other regional findings (eg, perioral changes/
•Infants/children: facial, neck, and b. IgE reactivity periauricular lesions)
extensor involvement 5. Perifollicular accentuation/lichenification/prurigo
•Any age group: current or previous 3. Xerosis lesions
flexural lesions
•Sparing of the groin and axillary regions
b. Chronic or relapsing history

Exclusionary Conditions

Diagnosis of AD depends on excluding conditions

•Scabies •Seborrheic dermatitis •Photosensitivity dermatoses
•Psoriasis •Contact dermatitis (irritant or allergic) •Immune deficiency diseases
•Ichthyoses •Cutaneous T-cell lymphoma •Erythroderma of other causes
AD, atopic dermatitis; IgE, immunoglobulin E. Adapted from Eichenfield et al.14

tailor it based on patient age, preferences for formulation of topical Sensitization for food and
previous treatment failures, who is antiinflammatories, as well as environmental allergens can be
providing care (for children/infants), consideration for the cost of identified by using skin prick or
lesion location (topical corticosteroid medication. It should be noted that specific IgE tests, and contact allergy
use must be limited in potency and different formulations of the same may be assessed through patch
duration of application for sensitive topical corticosteroid, even the same testing. However, providers should
skin areas), patient’s insurance and concentration of topical not suggest routine testing in the
financial resources to get corticosteroid, may have different search for “causes” of AD, because the
medications, patient/family lifestyle potencies, for example mometasone predictive value of positive tests is
(ie, time for baths and moisturizer/ furoate 0.1% ointment is high low, and often true clinical allergies
topical antiinflammatory application), potency (Class II), whereas may be irrelevant as AD triggers (eg,
and patient preferences (look/feel of mometasone furoate 0.1% cream is may cause a reaction such as
ointments versus creams). Patient/ medium potency (Class III–IV; urticaria, or itch, without necessarily
caregiver preferences are especially Table 3). flaring AD).9,13 “Relevant” allergens
important when selecting Determination of patient-specific AD differ by age group: young children
a moisturizer formulation because triggers is challenging, but if these are more likely to have food allergy
xerosis is the central feature of AD. triggers can be identified, avoidance (although the minority of infants and
Lotions contain preservatives, may lead to longer intervals between children who show reactivity through
fragrances, and other chemicals, flares and even complete disease prick or blood testing have true
which may cause allergic or irritant clearance in some cases. Nonspecific clinical allergy), whereas older
reactions. Lotions have a high water triggers may include harsh soaps, children and adults are more likely to
content and, especially for more detergents, wool, and other abrasive have sensitivity to aeroallergens.9,13
severely xerotic patients, may be fabrics, tight-fitting clothing, certain Many patients experience sleep
drying; moisturizer ointments with chemicals (eg, formaldehyde used for disturbance, especially during flares,
higher oil content and no fabric sizing), airborne irritants which not only negatively affects
preservatives may be preferable.9,11 (tobacco smoke, air pollution), and quality of life, but may also increase
The choice of moisturizer should be extremes or transitions in the risk of hyperactivity–impulsivity
based on patient preference/ temperature and humidity. Rarely, and other mental health disorders.
tolerance for the occlusiveness of allergies can be triggers of dermatitis, Positive associations between AD and
ointments and oils versus creams or and food and environmental allergies attention-deficit/hyperactivity
lotions. Similar considerations should are more common in children with disorder,26–30 anxiety disorders,26,30
be made for patient/caregiver AD than in those without.13 depression,30 and autism spectrum

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6 EICHENFIELD et al
TABLE 3 Topical Corticosteroid Potencies, Strengths, and Formulations when to step-up or step-down
Class Strength, % Available Formulations treatment, when to seek medical
advice, what triggers to avoid, etc, is
Drug Ointment Cream Lotion Foam Solution Gel
critical to ensuring good long-term
I. Very high potency treatment adherence. The current
Augmented betamethasone 0.05 ✓
conversion to electronic medical
dipropionate
Clobetasol propionate 0.05 ✓ ✓ ✓ ✓ records presents an opportunity to
Diflorasone diacetate 0.05 ✓ automate plan creation. In addition,
Halobetasol propionate 0.05 ✓ ✓ treatment plan handouts are freely
II. High potency available for duplication and
Amcinonide 0.1 ✓ ✓ ✓
distribution to patients and/or
Augmented betamethasone 0.05 ✓
dipropionate caregivers.38
Betamethasone dipropionate 0.05 ✓ ✓ ✓ ✓
Desoximetasone 0.25 0.25 0.05 Patient and Caregiver Education
Diflorasone diacetate 0.05 ✓ It is important for patients,
Fluocinonide 0.05 ✓ ✓ ✓ ✓
caregivers, and family members to
Halcinonide 0.1 ✓ ✓
Mometasone furoate 0.1 ✓ understand the chronic
Triamcinolone acetonide 0.5 ✓ ✓ relapsing–remitting nature of AD and
III–IV. Medium potency how the implementation of a written
Betamethasone valerate 0.1 ✓ ✓ ✓ ✓ treatment plan, including proper skin
Clocortolone pivalate 0.1 ✓
care, antiseptic measures, trigger
Desoximetasone 0.05 ✓
Fluocinolone acetonide 0.025 ✓ ✓ avoidance, and pharmacologic
Flurandrenolide 0.05 ✓ ✓ treatment, can help to extend periods
Fluticasone propionate 0.005 0.05 of remission. The process of patient/
Mometasone furoate 0.1 ✓ caregiver education should start with
Triamcinolone acetonide 0.1 ✓ ✓
the initial plan development and
V. Lower-medium potency
Hydrocortisone butyrate 0.1 ✓ ✓ ✓ continue through each follow-up visit
Hydrocortisone probutate 0.1 ✓ (especially when the treatment plan
Hydrocortisone valerate 0.2 ✓ ✓ has been modified) with the
Prednicarbate 0.1 ✓ physician, nurse, or other medical
VI. Low potency
staff to ensure that the current
Alclometasone dipropionate 0.05 ✓ ✓
Desonide 0.05 ✓ ✓ ✓ ✓ treatment plan is well understood.
Fluocinolone acetonide 0.01 ✓ ✓ Additionally, time spent on education
VII. Lowest potency affords the physician (or other HCP)
Dexamethasone 0.1 ✓ the opportunity to correct any
Hydrocortisone 0.25, 0.5, 1 ✓ ✓ ✓ ✓
misconceptions patients and/or
Hydrocortisone acetate 0.5–1 ✓ ✓
caregivers may have and to
Includes representative examples and not all available agents. Adapted from Paller and Mancini.18
proactively address any potential
insurance or dispensing issues, if
disorders30 have been reported, adherence and patient/caregiver required.
especially among patients with AD satisfaction and comfort level with Patients/caregivers should be
and sleep loss.28–30 In patients who the plan. Early follow-up may lead to instructed on proper skin care,
have a major complaint of sleep loss better adherence and better including skin hydration with warm
or who have risk factors for 1 or more treatment outcomes. soaking baths or showers,
of these mental health comorbidities, immediately followed by application
antihistamines (hydroxyzine or to damp skin of an adequate amount
TREATMENT PLAN IMPLEMENTATION
doxepin),31 topical of moisturizer (Fig 2).8,9,11 In
AND COMMUNICATION WITH PATIENTS
antiinflammatories,32–34 emollients,35 addition, adding a small amount of
AND CAREGIVERS
hypnotherapy,36 and/or reducing bleach (sodium hypochlorite; ∼0.5
sensory input37 may be beneficial. Written Treatment Plan cups per 40 gallons of water/full
Finally, all treatment plans should Incorporating instructions into bathtub or 1 mL/L) on a twice weekly
include scheduled follow-up a written plan (similar to what is basis has been shown to reduce AD
(telephone call, office visit, etc), commonly implemented for asthma severity.39 Daily use of these dilute
optimally within 1 to 2 weeks after patients) regarding when to apply bleach baths, or comparable sodium
the initial visit, to assess treatment moisturizers and topical medications, hypochlorite-based products while

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PEDIATRICS Volume 136, number 3, September 2015 7
FIGURE 2
Topical application amounts. aMeasurements/quantities are relative to adult hand/finger sizes, regardless of age group. bQuantity for creams should be
increased by ~10% over ointment.30 cQuantity for moisturizers may exceed the suggested values. dEstimated based on monthly amounts for 2 to 3 times
weekly application per Ring et al.7 FTU, fingertip unit.

showering or otherwise washing,40 of topical corticosteroid penetration measured from the distal skin crease
may be needed as part of and infection. For complete step-by- to the tip of the palmar surface of an
maintenance therapy for moderate to step directions, see Nicol et al.43 adult’s index finger. This is equal to
severely affected children (although Patients/caregivers should be ∼0.5 g and is an amount adequate for
the effect of managing bacterial advised to avoid nonspecific irritants “thin and even” application to an area
colonization alone on recurrent by using mild soaps or soap-free of skin equal to ∼2 adult hands with
infection has not been established41). cleansers, wearing “smooth”/ fingers together. The number of FTUs
The technique can be modified for nonirritating clothing that is loose- required to treat different body areas
more local soaking or compressing fitting, and avoiding detergents and varies with patient age, but FTUs are
for maintenance of areas that more fabric softeners with fragrances.9,13 measured relative to adult hands/
often show secondary infection or for In addition, exposure to aeroallergens fingers regardless of age (Fig 2).
patients with current infection who (molds, dust mites, pollen, animal Providers may also find it helpful to
cannot tolerate bathing. Proper skin dander, airborne irritants), and prescribe specific amounts of
care will also help reduce exposure extremes in temperature and a topical agent to be used over the
and/or impact of certain AD triggers humidity may be avoided, or course of 1 week or month to ensure
by increasing the patient’s threshold minimized through the use of air proper use of topical corticosteroids,
for skin irritation. conditioning and/or air filters.9 TCIs, and/or moisturizer (Fig 2).
Wet-wrap therapy (WWT; with or Patients/caregivers should also be Asking patients/caregivers to bring
without topical corticosteroids) may instructed on avoidance strategies for their partially used bottles/tubes into
reduce disease severity, especially for AD triggers specific to them (ie, foods, the office during their next visit may
patients with moderate-to-severe AD contact and aero-allergens) as be helpful in assessing adherence
during flares11; however, WWT can determined through plan (although the possibility of
be time-consuming and complicated. optimization and individualization medication “dumping” should be kept
Patients/caregivers should be (above). in mind). Despite proper instruction,
instructed in the application of loose, some patients/caregivers may still
It is also critically important to
wetted (soaked in warm water, then not apply adequate amounts of
instruct patients/caregivers on the
wrung out until slightly damp) topical corticosteroids because of
quantity of topical medication and
tubular bandages, gauze, or cotton a fear of side effects (ie, “steroid
moisturizer to use for each
clothing over topical corticosteroid or phobia”). Making patients/caregivers
application and the total quantity
moisturizer, followed by a dry outer aware of the signs of skin atrophy (eg,
expected to be consumed per week or
increased transparency and shininess
layer of similar material (never month (Fig 2). The fingertip unit
plastic wrap), which may be worn for of the skin; striae) and explaining that
(FTU) has been developed as
several hours to 24 hours and mild cutaneous side effects are
a helpful tool for quantitatively
repeated for several days to 2 reversible with time (but striae are
describing for patients/caregivers the
weeks.42 Care should be taken during not) may allay some of these fears
amount of topical medication to be
WWT, especially when using used.44,45 It is defined as the amount and increase adherence.
medium-to-high potency topical of ointment expressed from a tube Written plans and patient/caregiver
corticosteroids, due to increased risk with a 5-mm diameter nozzle education have the potential to

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8 EICHENFIELD et al
improve treatment adherence, which find the following Web sites to be treatment with TCI and/or topical
is a major determinant of treatment helpful resources: corticosteroids for patients with
success. There are a number of • NEA: http://nationaleczema.org moderate-to-severe disease. Because
additional strategies pediatricians the course of AD varies from patient
• AD information from the Asthma
and PCPs can use to improve to patient, it is critical to design
and Allergy Foundation of America:
adherence among their patients, treatment plans based on patients’/
http://www.aafa.org/display.cfm?
including engaging patient and caregivers’ individual preferences and
id=9&sub=23&cont=325
caregivers in discussions about needs including patient age, family
previous medications/experiences, • The Eczema Center at Rady lifestyle, preference for topical
suggesting support from groups such Children’s Hospital San Diego: treatment formulation, and pattern of
as the National Eczema Association http://eczemacenter.org lesions and flares. Patient and
(NEA; http://nationaleczema.org/), • Northwestern Multidisciplinary caregiver education should include
addressing side effects proactively, Eczema Center: http://eczema.nm. a written treatment plan and
positive reinforcement, frequent org instruction on trigger avoidance and
follow-up visits, accessing managed • The Pediatric Atopic Dermatitis correct topical treatment application.
care compliance and care Program at National Jewish Health: Treatment plans should be
management programs, and, in the http://www.nationaljewish.org/ continually optimized and refined
most noncompliant patients, applying programs/pediatric/atopic- during regular follow-ups.
medications in the office. Sticker dermatitis
charts may be a particularly useful ACKNOWLEDGMENTS
• AD information from the AAD:
tool for improving adherence among All roundtable and article content
http://www.aad.org/dermatology-
pediatric patients.46 Many patients/ was developed independent of
a-to-z/diseases-and-treatments/
caregivers may wish to discuss funding source. Jennifer Jaworski, MS,
a---d/atopic-dermatitis
complementary and alternative a full-time employee of Prescott
therapies; these should be reviewed • AD information from the National
Medical Communications Group
in an open-minded way, although at Institute of Arthritis and Musculo-
(Chicago, IL) assisted with
this time there is limited clinical data skeletal and Skin Diseases: http://
preparation of the article at the
supporting their use.13 Consideration www.niams.nih.gov/Health_Info/
direction of the authors with financial
of referral to a child psychologist is Atopic_Dermatitis
support from Valeant.
appropriate in cases where
behavioral support beyond patient CONCLUSIONS
and caregiver education is needed. Pediatricians and other PCPs play ABBREVIATIONS
The NEA is a valuable resource for a central role in the management of
patient/caregiver education and AAAAI: American Academy of
AD, be it by referring patients with Allergy, Asthma and
support. Educational brochures are moderate-to-severe AD for
available for distribution by Immunology
specialized care, providing ongoing AAD: American Academy of
providers. Regarding skin care maintenance care after evaluation by
products, NEA maintains a list that Dermatology
specialists, or managing patients with ACAAI: American College of
have satisfied the NEA Seal of mild or more episodic AD themselves.
Acceptance criteria for sensitivity, Allergy, Asthma and
The treatment model proposed in this Immunology AD: atopic
safety, and toxicity, as well as article is designed specifically for use
ingredients, content, and formulation. dermatitis
by pediatricians and other PCPs and EDF: European Dermatology
In addition, providers may find it includes basic management measures
helpful to form cooperative groups of Forum
(skin care, antiseptic measures, and FTU: fingertip unit
HCPs within their practice or local trigger avoidance) to be used
area to facilitate coordination of care, HCP: healthcare provider
regardless of AD severity, acute NEA: National Eczema Association
information sharing, and pooling of treatment of flares with low or
resources. PCP: primary care provider
medium potency topical TCI: topical calcineurin inhibitor
Patients/caregivers as well as corticosteroids depending on severity WWT: wet-wrap therapy
pediatricians and other PCPs may of the flare, and maintenance

Address correspondence to Lawrence F. Eichenfield, MD, Pediatric Dermatology, Rady Children’s Hospital, 8010 Frost St, Suite 602, San Diego, CA 92123. E-mail:
leichenfield@rchsd.org

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PEDIATRICS Volume 136, number 3, September 2015 9
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2015 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Funded by Valeant Pharmaceuticals North America, LLC.
POTENTIAL CONFLICT OF INTEREST: Dr Eichenfield has been a principal investigator for Astellas Pharma US, Inc, Galderma Laboratories, LP, and Stiefel Laboratories,
Inc; he has received compensation for his work as a consultant for Valeant Pharmaceuticals North America, LLC, Anacor Pharmaceuticals, Inc, Galderma, Promius
Pharma, LLC, and Stiefel, TopMD, Inc; Drs Boguniewicz and Simpson have received financial compensation for their work as consultants for Valeant Pharmaceuticals
North America, LLC; Dr Russell has received financial compensation for his work as a consultant for Valeant Pharmaceuticals North America, LLC, as a Speakers
Bureau member for SanofiPasteur US, and as an Advisory Board member for Takeda Pharmaceuticals USA, Inc; Ms Block is a salaried executive of National Eczema
Association, which has received grants and sponsorship awards from a variety of industry partners including Valeant Pharmaceuticals North America, LLC (full list
at: http://nationaleczema.org/corporate-partners/); Dr Feldman has received research, speaking and/or consulting support from a variety of companies including
Valeant Pharmaceuticals North America, LLC, Astellas Pharma US, Inc, AbbVie, Inc, Advance Medical, Amgen, Inc, Anacor Pharmaceuticals, Inc, Baxter, Boehringer
Ingelheim GmbH, CVS/caremark, Celgene Corporation, Eli Lilly and Company, Galderma Laboratories, LP, Informa Healthcare, Janssen Pharmaceutical, Inc, Leo
Pharma, Inc, Pfizer, Inc, Merck & Co, Inc, Merz Pharma GmbH & Co KGaA, Mylan, Inc, National Biological Corp, Novartis Corporation, Qurient Co, Ltd, Stiefel
Laboratories, Inc, Suncare Research Laboratories, LLC, UpToDate, Inc, and National Psoriasis Foundation, and Dr Feldman is founder and part owner of Causa
Research, a company dedicated to enhancing patients’ adherence to treatment; Ms Clark has been a subinvestigator for Astellas Pharma US, Inc, Medicis
Pharmaceutical Corporation (now part of Valeant), Galderma Laboratories, LP, Anacor Pharmaceuticals, Inc, Stiefel Laboratories, Inc, Maruho Co, Ltd, Merz Pharma
GmbH & Co KGaA, Regeneron Pharmaceuticals, Inc, and HanAll Biopharma, and she has received financial compensation for her work as a consultant for Valeant
Pharmaceuticals North America, LLC; Ms Tofte has received financial compensation for her work as a consultant for Valeant Pharmaceuticals North America, LLC,
and as Advisory Board member for Amgen, Inc, and Johnson & Johnson Consumer & Personal Products Worldwide; Dr Dunn has received financial compensation
for his work as a consultant for Valeant Pharmaceuticals North America, LLC, and Stiefel Laboratories, Inc; Dr Paller has been a principal investigator for Anacor
Pharmaceuticals, Inc, Astellas Pharma US, Inc, and TopMD, Inc, and she has received financial compensation for her work as a consultant for Valeant
Pharmaceuticals North America, LLC, Anacor, Galderma Laboratories, LP, Onset Dermatologics, Promius Pharma, LLC, and Stiefel Laboratories, Inc.

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12 EICHENFIELD et al
 Translating Atopic Dermatitis Management Guidelines Into Practice for
Primary Care Providers
Lawrence F. Eichenfield, Mark Boguniewicz, Eric L. Simpson, John J. Russell, Julie
K. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, Jeffrey D. Dunn and Amy
S. Paller
Pediatrics; originally published online August 3, 2015;
DOI: 10.1542/peds.2014-3678
Updated Information & including high resolution figures, can be found at:
Services http://pediatrics.aappublications.org/content/early/2015/07/28
/peds.2014-3678
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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 Translating Atopic Dermatitis Management Guidelines Into Practice for
Primary Care Providers
Lawrence F. Eichenfield, Mark Boguniewicz, Eric L. Simpson, John J. Russell, Julie
K. Block, Steven R. Feldman, Adele R. Clark, Susan Tofte, Jeffrey D. Dunn and Amy
S. Paller
Pediatrics; originally published online August 3, 2015;
DOI: 10.1542/peds.2014-3678

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2015/07/28/peds.2014-3678

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2015 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from pediatrics.aappublications.org by guest on August 25, 2015