New AD tx algorithm outlines severity-based approach to care

A recently developed algorithm has been designed to provide a simple, stepwise approach to the management of atopic dermatitis (AD) based on disease severity, says its creator Lawrence F. Eichenfield, M.D., chief of pediatric and adolescent dermatology, Children's Hospital, San Diego, and clinical professor of pediatrics and medicine (dermatology), University of California San Diego School of Medicine.

The algorithm, which appears in a paper by Dr. Eichenfield discussing the development of consensus guidelines on AD diagnosis and treatment (Eichenfield LF. Allergy. 2004;59(Suppl 78):86-92), divides AD into three severity categories - mild, moderate, and severe - based on disease extent and/or persistence. Similar to asthma guidelines issued by the National Heart, Lung and Blood Institute and National Asthma Education and Prevention Program, it outlines three "steps of therapy" for each severity category corresponding to low-level maintenance measures, interventions for higher maintenance or breakthrough and a strategy for exacerbation.

Skin care Good skin care, including twice daily emollient application, together with avoidance of irritants and specific allergens are presumed base therapy for all patients. The algorithm provides guidelines for introducing topical corticosteroids of varying potencies for flare control according to disease severity, and it incorporates topical calcineurin inhibitors as alternatives to corticosteroids for controlling flares and as mainstays for long-term intermittent control.

"This severity-based algorithm has not yet been fully evaluated in clinical practice, but there was thought to be a need to develop it after having been asked several times about the availability of an AD algorithm by persons responsible for administering managed care prescription formularies. Dermatologists know intuitively how to escalate treatment for worsening AD, but until now, there has been no formal publication describing a stepwise, severity-based approach," notes Dr. Eichenfield.

Other consensus statements Recently, consensus statements on AD and guidelines of care have been issued by other groups, including the American Academy of Dermatology, the International Consensus Conference on Atopic Dermatitis II (ICCAD II), and the Cochrane Skin Group. However, the AAD and Cochrane Skin Group efforts represent evidence-based reviews of treatment rather than algorithms for care. An algorithm issued as a result of the ICCAD II may be functional for dermatologists, although non-dermatologists might find it more difficult to apply since it does not define disease severity nor provide guidelines about moving between levels of care, Dr. Eichenfield observes.

"The new algorithm was designed to be equally useful for dermatology specialists and primary care physicians and is unique in that it recommends management approaches based on disease severity. An important feature is the recognition that needs for long-term care differ depending on whether the disease is mild, moderate or severe," he says.