Evidence-Based Guidelines Needed for Efficient, Secure AD Treatment, Review Says

Evidence-based clinical practice guidelines for atopic dermatitis (AD) treatment are needed for primary care providers (PCPs) to deliver secure, efficient care to patients, according to a review published in Cureus.

The researchers noted that about 15% to 20% of children, and 2% to 10% of young people, are affected by AD. Because it is more prevalent in younger patients, primary care providers (PCPs) and general practitioners are frequently responsible for managing AD; however, despite this, little is known about their treatment methods.

Consequently, the researchers conducted a systemic review to investigate how PCPs manage AD in children and adults, including prescription, disease understanding, and counseling. More specifically, they examined if the PCPs used topical calcineurin inhibitors (TCIs), topical corticosteroids (TCSs), skin emollients, oral antihistamines, or diet when treating patients with AD.

To conduct their review, the researchers used keywords and Medical Subject Headings to search databases like PubMed for articles published in English from 2014 to August 2023. Eligible studies discussed AD, PCP involvement in AD, and management components like medication, counseling, and auxiliary testing. Through their search, the researchers identified 61 studies, but they ultimately included 15 in their review.

A theme that emerged through their review was PCPs’ use of low-potency TCS, such as hydrocortisone, as it is their first line of defense against AD flare-ups. They explained that TCSs affect several immune cells, including T lymphocytes and macrophages, which impair the processing of antigens and stifle the release of cytokines that promote inflammation. On the other hand, PCPs did not frequently recommend TCIs due to worries about lymphoma adverse effects despite numerous studies not finding a link between long-term TCI usage and a risk of malignancy.

Doctor treating child for topic dermatitis (AD)

Image credit: megaflopp - stock.adobe.com

The researchers also discovered that PCPs frequently prescribe patients with AD oral antihistamines. Despite their popularity, they explained that oral antihistamines are ultimately not recommended as they do not reduce itchiness. Conversely, the researchers noted that ultraviolet phototherapy appears to be a safe, effective treatment for patients with moderate to severe AD in which first-line treatments are inadequate.

Additionally, the review showed that newer medications approved by the FDA, like crisaborole and dupilumab, are effective treatments but are currently unaffordable for most patients.

As part of maintenance therapy, the authors wrote that PCPs frequently advise children with AD to liberally apply emollients; for better results, PCPs recommended using richer moisturizing products, like lotions and ointments. They explained that regular application of emollients reduces symptoms and lowers the requirement for topical anti-inflammatory drugs.

Lastly, the researchers only found a small amount of information on PCP management of food and allergy in patients with AD. They noted that “dietary restrictions may be ineffective and result in poorer nutrition, increased parental anxiety, and a higher risk of developing food allergies due to reducing the child’s chances of developing early tolerance to certain foods.”

The researchers also acknowledged their review’s limitations, one being that most studies analyzed relied on health care personnel reporting their typical behaviors instead of analyzing specific patient encounters. Also, the number of samples in each analyzed study was frequently small. Consequently, the researchers noted that the remaining knowledge gaps on AD treatment need to be filled.

“…there are gaps in knowledge and management of critical topics, such as prescribing TCIs and understanding the safety profiles of TCS, when it comes to treating adult and pediatric AD,” the authors wrote. “Future research in this area is urgently needed because the current systemic assessment is mostly restricted to small studies that assess prescribing behaviors with scant information describing nonmedication management.”

Reference

Alqahtani SM, Awaji BH, Mahdi AM, et al. Assessment and management of atopic dermatitis in primary care settings: a systematic review. Cureus. 2023;15(9):e44560. doi:10.7759/cureus.44560