Guidelines for Management of Atopic Dermatitis — Part 1: Diagnosis and Assessment

Lawrence F. Eichenfield, MD (Co-chair), Wynnis L. Tom, MD, Sarah L. Chamlin, MD, MSCI, Steven R. Feldman, MD, PhD, Jon M. Hanifin, MD, Eric L. Simpson, MD, Timothy G. Berger, James N. Bergman, David E. Cohen, Kevin D. Cooper, Kelly M. Cordoro, Dawn M. Davis, Alfons Krol, David J. Margolis, Amy S. Paller, Kathryn Schwarzenberger, Robert A. Silverman, Hywel C. Williams, Craig A. Elmets, Julie Block, Christopher G. Harrod, Wendy Smith Begolka, Robert Sidbury

AADBackground and Objective
Atopic dermatitis (AD) is a chronic, inflammatory dermatosis that begins before 5 years of age in 90% of patients. It has a complex pathogenesis in which genetic and environmental factors cause perturbations in the skin barrier and immunological function. A working group of recognized AD experts assembled to develop a four-part evidence-based guideline for AD care. This replaces a 2004 American Academy of Dermatology guideline on the same topic. Part 1 of the new guideline emphasizes clinical questions about the diagnosis and assessment.

Key Points

  • Diagnosis AD is based on clinical findings, which include a compatible history, morphology, and distribution of lesions.

  • Although serum IgE levels, peripheral blood eosinophil counts, and tissue mast cells are often elevated in AD, they are not reliable indicators; under most circumstances, they are not useful for diagnosis, nor do they have sufficient sensitivity or specificity for monitoring disease course.

  • Several sets of diagnostic criteria have been proposed. These are helpful for clinical trials but mostly impractical for routine clinical care.

  • Although these markers are not typically employed clinically, high total serum IgE levels and filaggrin null gene mutations portend a worse and more chronic course.

  • Objective quality-of-life indexes and disease-impact measures indicate that pruritus is responsible for much of the burden of the disease for patients and families; 60% of AD patients have sleep disturbance, a rate rising to 83% during disease flares.

  • Although food allergies are more common in these patients, no evidence supports specific dietary measures as helpful in preventing development of AD.

  • House-dust-mite allergy is common in AD patients, but avoidance has not been shown to prevent AD.

  • Recent reports suggest an association with attention-deficit/hyperactivity disorder, but the nature of that association has not been determined.

  • The two major risk factors for AD are family history of atopic disease and loss-of-function mutations in the filaggrin gene; the protein product of filaggrin is important for epidermal hydration and skin barrier function.

  • AD is more common in urban areas and in the black population. At one time, it was thought that AD was more common in higher socioeconomic groups, but more-recent studies have not supported this.

Comment
These guidelines provide valuable information that should help practitioners apply the most current evidence on diagnosis, assessment of risk factors, and comorbidities to patient care. For example, it is common practice to use IgE levels and serum eosinophils for diagnosis and assessment of disease activity, although there is little evidence that these parameters are helpful. Dietary measures and house-dust-mite avoidance are often undertaken to block development of atopic dermatitis, but there is no evidence that these practices result in effective prevention.