The latest update to the consensus-based European guidelines for the treatment of atopic dermatitis in adults and children was published in May this year, replacing the previous set of European guidelines published in July 2012.

The changes and new additions in the update were explained at the 27th European Academy of Dermatology and Venerology (EADV) Congress in September. Along with language being standardised, some of the topics amended or added included:

  • The addition of a chapter covering patient perspective
  • Updated advice on patient lifestyle, such as complementary foods for children that are four to six months of age and no longer recommending wearing silk garments coated in 2-trimethylsilylpropyl-dimethyloctadecyl ammonium chloride (AEGIS), as these garments do not improve eczema severity over standard of care treatment
  • No longer recommending that children with atopic dermatitis be vaccinated on a different schedule than regular vaccination patients (except for the smallpox vaccine)
  • Updated recommendations for systemic therapies, including oral corticosteroids, cyclosporine, and Sanofi/Regeneron’s Dupixent (dupilumab)
  • Recommendations for patient education programs for both child and adult patients as part of basic therapy

In terms of changes to recommendations on topical therapies, the previous recommendations for topical corticosteroids (TCS) have been kept and expanded upon. The application of diluted TCS used under wet wraps for short-term periods in acute atopic dermatitis is now advocated for in order to increase the efficacy of wet wrap therapy.

Moreover, safe proactive therapy with TCS has now become supported for at least a 20-week period, the longest safe duration tested by trials. Patients’ fear of TCS’ side effects (including localised skin atrophy, formation of stretch marks, and easy bruising), termed ‘cortico-phobia’ by the new guidelines, should now be recognised and addressed by prescribing physicians in order to improve treatment adherence and outcome for patients. With regards to topical calcineurin inhibitors (TCI), the new guidelines merely add that acute flairs should be initially treated with TCS before switching to TCI due to some patients experiencing a transient worsening of symptoms when applied to acutely inflamed skin. Although not an official recommendation, the new guidelines do emphasise that clinicians should make patients aware of the boxed warning for TCI, despite the fact that the summary of product characteristics does not distinguish between ointment, tablet, and gel forms.

Recommendations for systemic therapies have also been updated. The stance on oral glucocorticosteroids has not changed, except for an upper limit of 0.5mg/kg bodyweight being imposed. The recommended cyclosporine starting dose has also been changed from 2.5mg/kg–3.5mg/kg/day to 5mg/kg/day, and the new guidelines have noted that cessation of cyclosporine therapy or switching to another systemic drug should only be attempted after two years of therapy. Other systemic immunomodulators also have updated recommendations. Azathioprine is now allowed to be used in children and pregnant women (with strict indication). The upper dose for mycophenolate mofetil (MMF) has been increased to 3g/day and can be used in children and adolescents, although it is teratogenic and cannot be taken by pregnant women. Methotrexate can be used in children as well as adults, with the recommended dosing regimen being similar to or slightly lower than that used in treating psoriasis (10mmg–25mg/week), but it is also teratogenic in pregnant women.

Previously, recommendations for biologic treatment were minimal, as no biologic therapies were available for atopic dermatitis patients at the time. As such, earlier guidelines dictated that anti-psoriatic biologics (omalizumab, rituximab, ustekinumab) could be considered for severe patients. However, the most recent set of guidelines has acknowledged that dupilumab—the first and currently only approved biologic for atopic dermatitis—is suitable for long-term use. It has been recommended as a disease-modifying drug for patients with moderate-to-severe disease in whom topical treatment is not sufficient and other systemic therapies are not advisable.

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Overall, the new set of European guidelines from the European Dermatology Forum have comprehensively revised the guidance related to more established therapies (TCS, TCI, and systemic immunosuppressants) in order to make recommendations more specific, as well as consulting safety data that has been released since the last edition of the European guidelines. Furthermore, new sections have been added to cover the newly approved biologics specific to atopic dermatitis treatment.