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    • br Introduction Atopic dermatitis AD

    2018-10-29


    Introduction Atopic dermatitis (AD) is a common inflammatory disease that appears to have increased in prevalence over the past few decades. The prevalence of AD in Taiwan is estimated to be approximately 6.7% based on the National Health Insurance database for 2000–2007. More specifically, the prevalence ranged from 1.7% to 3.35% in 2002, but has roughly doubled since then. From the investigation of The International Study of Asthma and Allergies in Childhood, the prevalence of AD in Taiwan in the 6–7 year age group was increased from 3.5% in phase I to 6.7% in phase II; in the 13–14 year age group, the prevalence increased from 1.4% in phase I to 4.1% in phase II. The increase of prevalence is especially prominent in teenagers. Although AD is common in childhood, it PD 0332991 may also occur in adulthood. Adult-onset AD is defined by the first appearance of AD symptoms after the age of 20 years. Adult-onset AD differs from classical AD by preferentially affecting the face, hands, and nonflexural areas and frequently presents as a prurigo-like pattern. Early and/or current exposure to cigarette smoking may contribute cumulatively to the development of adult-onset AD. AD is a chronic relapsing disease that may last for several months or years. Family aggregation is commonly associated with AD, and the disease has physiological, psychological, and social impacts. AD requires a holistic assessment by healthcare practitioners, and a multidisciplinary, team-based approach involving dermatologists, general practitioners, pediatricians, respiratory specialists, allergologists, nurses, psychologists, nutritionists and social workers to provide proper care. Physicians should focus on the current treatment plan while aiming to improve overall safety and quality of life. In Taiwan, the prevalence and impact of atopic dermatitis are dependent to some extent on various socioeconomic conditions, varying climates, and patient access to available therapies. With those factors in mind, the current treatment consensus has been developed to provide up-to-date and concise evidence- and experience-based recommendations directed towards general practitioners and general dermatologists in Taiwan regarding the management of pediatric and adult AD. The information in the consensus was agreed upon by a panel of national experts who convened at Taiwanese Dermatological Association (TDA) AD consensus meetings held on March 16, May 4, and June 29, 2014, with all of the specific aspects of the content requiring approval by at least 75% of the experts in attendance.
    Materials and methods
    Results The consensus recommendations stratified by different lines of treatments for AD were approved by the participants with ratings of 7–9 accounted for 84% of the total votes cast (Table 1). The first line treatments include emollients, topical corticosteroids (TCSs), antihistamines and therapeutic patient education; the second line treatments include topical calcineurin inhibitors (TCIs), burst use of systemic corticosteroids, phototherapy, and topical/systemic antibiotics, while the third line treatments include systemic immunomodulatory agents, antiseptics, and alternative medicine. The use of emollients and TCSs both obtained 100% of the participants rating 7–9 (Tables 2 and 3), antihistamines were agreed by 96% of the participants (Table 4), and therapeutic patient education was approved by 100% of the experts (Table 5). Among the second line treatments, the percentages of rating 7-9 by the participated experts were TCIs 100% (Table 6), burst use of systemic corticosteroids 96% (Table 7), phototherapy 100% (Table 8), and topical/systemic antibiotics 100% (Table 9). The consensus recommendations of systemic immunodulatory treatments for AD were approved by the 95.6% of participants (ratings of 7–9; Table 10), while the consensus recommendations of antiseptics and alternative medicine treatments for AD were approved by 100% and 95.6% of the experts, respectively (Tables 11 and 12). After confirming these three lines of treatment, the committee proposed an algorithm of treatment stratified by three steps in real practice (Figure 1). The initial assessment should include a detailed history and extent/severity of AD, followed by the first step of treatment with emollients, therapeutic patient education and avoidance of irritants/allergens. When the disease activity flares acutely, immediate control of pruritus and inflammation by antihistamines and TCSs is recommended. If the symptoms improve, the Step 2 maintenance therapy such as TCIs, proactive or intermittent treatment with TCSs could be used. If the symptoms aggravate after Step 1 treatment, burst use of systemic corticosteroids, phototherapy, or control of infections might be needed. If these intensive treatments still do not work, the third step treatments such as systemic immunomodulatory agents, potent TCSs, aggressive phototherapy, alternative medicine or psychotherapeutic approach might be helpful. All the patients may shift to maintenance therapy once the AD symptoms are controlled after Step 3 treatment or intensive treatment, and they may further change to Step 1 basic care if the AD lesions achieve complete remission (Figure 1).