Therapeutic Guidelines for Atopic Dermatitis 2002 - Allergology ...

Allergology International. 2005;54:45-49REVIEW ARTICLETherapeutic Guidelines for AtopicDermatitis 2002Masutaka Furue 1 ,YoichiKohno 2 , Shoso Yamamoto 3 on behalf of The Research Group for TherapeuticGuideline Construction on Atopic Dermatitis: Toshiyuki Aoki, Kazuo Akiyama, Shuhei Imayama,Akira Ozawa, Takanobu Kurashige, Osamu Koro, Tuyoshi Sakane, Naoki Shimojo, Yoichi Tanaka,Kunihiko Tamaki, Shinpei Torii, Hidemi Nakagawa, Hideo Nakayama, Sankei Nishima,Fukumi Furukawa, Mitsufumi Mayumi, Masako Mizoguchi, Eishin Morita, Naomi Yamashita andKazuya YamamotoABSTRACTWe summarized the Therapeutic Guidelines for Atopic Dermatitis 2002, and outlined important points with referenceto medical care and management of atopic dermatitis.KEY WORDSanti−histamine, atopic dermatitis, steroid, tacrolimus, therapeutic guidelinesINTRODUCTIONThe Therapeutic Guidelines for Atopic Dermatitis1999 were first announced by the Research Group forTherapeutic Guideline Construction on Atopic Dermatitis(Director : Shoso Yamamoto), which was supportedby the Japanese Ministry of Health, Labourand Welfare. These guidelines were further updatedin 2001 and 2002. They target general physicians .The structure of these guidelines corresponds withthat of the treatment guidelines proposed by the JapaneseDermatological Association, which are aimed atdermatologists ( http : web . kanazawa-u . ac . jp med24atopytherapy.html). The classification of thepotency of topical steroids was unified in both guidelinesAlthough analysis of the pathogenesis and relatedgenes for atopic dermatitis ( AD) is currently progressing,this work has not yet elucidated the fundamentalcause of AD. AD is a common, chronic orchronically relapsing, severely pruritic, eczematousskin disease. Therefore, the patient’s discomfort islargely similar to that in other intractable skin diseases.In order to achieve good communication withpatients, it is important for physicians to carefully listento how patients describe their discomfort, sometimesover a period of many hours. It is also a prerequisiteto help patients understand that the medicationcurrently prescribed is a disease-adapted treatment,although very useful to control disease activity,and to understand that the majority of patients experiencespontaneous regression during follow-upDIAGNOSISThe symptoms of AD chronically fluctuate with remissionsand relapses, and many patients have atopicdiathesis. The Japanese Dermatological Associationhas established criteria for the diagnosis of AD (Table1). 1PRINCIPLES FOR THERAPYIt is important to treat each patient by appropriatelycombining the following three fundamental principles: (1) elucidation and avoidance of trigger and aggravatingfactors, (2) skin care, and (3) medication( Fig . 1). Information about medical treatmentsshould be explained fully to the patient to create agood doctor-patient partnershipGLOBAL CLINICAL SEVERITYIt is necessary to evaluate the global clinical severityin order to select a suitable treatment. Although sev-1Department of Dermatology, Graduate School of Medical Sciences,Kyushu University, Fukuoka, 2 Department of Pediatrics,Graduate School of Medicine, Chiba University, Chiba and 3 Departmentof Dermatology, Hiroshima University, Hiroshima, Japan.Correspondence: Masutaka Furue, Department of Dermatology,Kyushu University, 3 − 1 − 1 Maidashi Higashiku, Fukuoka 812 −8582, Japan.Email: furue@dermatol.med.kyushu−u.ac.jpReceived 19 January 2004.2005 Japanese Society of AllergologyAllergology International Vol 54, No1, 2005 www.js-allergol.gr.jp 45

Furue M et al.Table1 DefinitionandDiagnosticCriteriaforAtopicDermatitisbyTheJapaneseDermatologicalAssociationDefinitionAtopicdermatitisisapruritic,eczematousdermatosis,thesymptomsofwhichchronicalyfluctuatewithremissionsandrelapses.Mostindividualswithatopicdermatitishaveatopicdiathesis.Atopicdiathesis:(1)personalorfamilyhistory(asthma,alergicrhinitisand/orconjunctivitis,andatopicdermatitis),and/or(2)predispositiontooverproductionofimmunoglobulinE(IgE)antibodies.Diagnosis1.Pruritus2.Typicalmorphologyanddistribution:(1)Eczematousdermatitis・Acute lesions: erythema, exudation, papules,vesiculopapules,scalesandcrusts・Chroniclesions:infiltratederythema,lichenification,prurigo,scalesandcrusts(2)Distribution・SymmetricalPredilection sites:forehead,periorbitalarea,perioralarea,lips,periauriculararea,neck,jointareasoflimbs,trunk・Age-relatedcharacteristicsInfantilephase:startsonthescalpandface,oftenspreadstothetrunkandextremitiesChildhoodphase:neck,theflexuralsurfacesofthearmsandlegsAdolescentandadultphase:tendencytobesevereontheupperhalfofthebody(face,neck,anteriorchest,andback)3.Chronicorchronicalyrelapsingcourse(usualycoexistenceofoldandnewlesions):MorethantwomonthsininfancyMorethansixmonthsinchildhood,adolescence,andadulthoodDefinitediagnosisofatopicdermatitisrequiresthepresenceofalthreefeatureswithoutanyconsiderationofseverity.Othercasesshouldbeevaluatedonthebasisoftheclinicalcoursewiththetentativediagnosisofacuteorchronic,nonspecificeczema.DiferentialDiagnosis・Contactdermatitis・Seborheicdermatitis・Prurigosimplex・Scabies・Miliaria・Ichthyosis・Xeroticeczema・Handdermatitis(non-atopic)DiagnosticAids・Familyhistory(bronchialasthma,allergicrhinitisand/orconjunctivitis,atopicdermatitis)・Complications(bronchialasthma,alergicrhinitisand/orconjunctivitis)・Folicularpapules(goose-skin)・Elevatedserum IgElevelClinicalTypes(notapplicabletotheinfantilephase)・Flexuralsurfacetype・Extensorsurfacetype・Dryform inchildhood・Head/face/neck/upperchest/backtype・Prurigotype・Erythrodermatype・CombinationsofvarioustypesarecommonSignificantComplications・Ocular complications (cataracts and/or retinaldetachment):especialyinpatientswithseverefaciallesions・Kaposi’svariceliform eruption・Moluscum contagiosum・Impetigocontagiosaeral scoring systems have been reported for theevaluation of the severity of AD, we herein propose asimple method considering the affected body surfaceareas in order to make it convenient for general physiciansto use (Table 2).TRIGGER AND AGGRAVATING FACTORSBecause trigger and aggravating factors vary amongpatients (Fig. 2), it is necessary to know an individualpatient’s trigger and aggravating factors before recommendingavoidance of any of the known trigger oraggravating factors for AD.SKIN CAREPatients with AD have several functional abnormalitiesof the skin, such as decreased ability of moisture46 Allergology International Vol 54, No1, 2005 www.js-allergol.gr.jp

Therapeutic Guidelines for Atopic Dermatitis 2002DiagnosisEvaluation of SeverityEducation and Avoidance ofTrigger and Aggravating FactorsSkin Care(compensation for the functionalabnormalities of the skin)MedicationsFig.1 PrinciplesfortherapyInfantile(less than 2 years old)Childhood(2 to 12 years old)Adolescence and Adult(13 years old and older)FoodsSweatingEnvironmental factorsBacteria, fungietceteraEnvironmental factorsSweatingBacteria, fungiContact allergensStressFoodsetceteraBecause the trigger and aggravating factors vary among patients, it is important to carefullyelucidate the trigger and aggravating factors before recommending their avoidance.Fig.2 TriggerandAggravatingFactorsTable2 GlobalClinicalSeverityMildModerateSevereVerySevere:Beingcoveredwithmildskinlesions*only,irespectiveofbodysurfaceareaafected:Inflamed skin lesions*covering lessthan10% ofthebodysurface:Inflamed skin lesions covering morethan 10% butless than 30% ofthebodysurface:Inflamed skin lesions covering morethan30% ofthebodysurface*Mildskinlesions:Dryskin,scalingandfainterythema.*Inflamed skin lesions:Lesionswith erythema,papules,erosion,infiltration,lichenification,andsoon.maintenance, decreased threshold of itch sensationand tendencies toward bacterial and viral infections.It is known that these abnormalities are strongly relatedto the development of symptoms and aggravationof dermatitis. Suitable skin care is therefore requiredto compensate for these abnormalities (Table3).MEDICATIONSuitable medication is required to control cutaneousinflammation . Topical steroids and oral antihistamineanti-allergic drugs are the mainstay oftreatment of AD. Figure 3 shows fundamental topicalsteroid therapy according to severity grading in patientsless than 2 years old, 2 to 12 years old, and 13years old or older. Table 4 shows a classification ofthe potency of topical steroids. The following pointsare important for drug treatment. We must select thepotency and vehicle formulation of topical steroids accordingto the patient’s age and distribution andmanifestation of each eruption. We recommend thatgeneral physicians prescribe topical steroids of lowerpotency and smaller volume and for as short a periodof time as possible for facial lesions to reduce the occurrenceof adverse effects. The adverse effects oftopical steroids, such as teleangiectasia and skin atrophy,occur more frequently with longer periods of application.Physicians must monitor the potency anddosage of topical steroids for their patients. 2 If a patientsuddenly stops the application of topical steroids,the eruptions may exacerbate rapidly . Physiciansshould ask their patients to tell them when theyAllergology International Vol 54, No1, 2005 www.js-allergol.gr.jp 47

Therapeutic Guidelines for Atopic Dermatitis 2002Table4 PotencyoftopicalsteroidsStrongest0.05% clobetasolpropionate05% diflorasonediacetateVerystrong0.1% mometasonefuroate0.05% betamethasonebutyratepropionate0.05% fluocinonide0.064% betamethasonedipropionate0.05% difluprednate0.05% budesonide0.1% amcinonide0.1% diflucortolonevalerate1% hydrocortisonebutyratepropionateStrong0.3% deprodonepropionate0.1% dexamethasonepropionate0.12% dexamethasonevalerate0.1% halcinonide0.12% betamethasonevalerate0.025% beclomethasonedipropionate025% fluocinoloneacetonideMild0.3% prednisolonevalerateacetate0.1% triamcinoloneacetonide0.02% flumetasonepivalate0.1% alclometasonedipropionate0.05% clobetasonebutyrate0.1% hydrocortisonebutyrate1% dexamethasoneWeak0.5% prednisolone1% hydrocortisoneacetatemodulatory drug or calcineurin inhibitor) is effective,in particular for facial lesions. Treatment guidelinesfor use of topical tacrolimus can be found elsewhere. 3CHECKPOINTS DURING FOLLOW-UPOver long periods of follow-up, physicians must beaware of the possibility of various complications andmanage them appropriately. AD is frequently associatedwith impetigo contagiosum, Kaposi’s varicelliformeruption and molluscum contagiosum. Thesecomplications require early diagnosis and appropriatetreatment. AD is also frequently associated with ophthalmicdisorders such as cataract and retinal detachment. Repeated rubbing and patting of the orbitalarea may be responsible for the exacerbation of ophthalmiclesions. Special attention should be paid tothe occurrence of contact dermatitis due to topicalointments, because the contact dermatitis aggravatesthe severity of lesions. These guidelines only outlinethe general points of therapeutic management of AD,and therefore, many additional factors must be consideredin individual cases. Physicians have to considerreferring the patients to experts and specialclinics, if good control is not achieved after 1 monthof treatment according to these guidelinesREFERENCES1. Japanese Dermatological Association criteria for the diagnosisof atopic dermatitis. Jap. J. Dermatol. 1966;106:64-65.2. Furue M, Terao H, Rikihisa W et al. Clinical dose and adverseeffects of topical steroids in daily management ofatopic dermatitis. Br.J.Dermatol.2003;148:128-133.3. The Japanese FK 506 Ointment Study Group . Clinicalguidance for treatment of patients with atopic dermatitisby tacrolimus ointment 0.1% and 0.03%. Rinsho Hifuka2003;57:1217-1234 (in Japanese).Allergology International Vol 54, No1, 2005 www.js-allergol.gr.jp 49