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Background: Atopic dermatitis (AD) is a common and chronic, pruritic inflammatory skin
condition that affects all age groups. There was a dearth of consensus document on AD for
Indian practitioners. This article aims to provide an evidence‑based consensus statement for
the management of AD with a special reference to the Indian context. This guidel...
Context in source publication
Context 1
... use of moisturizer constitutes the core of the management of AD. A moisturizer repairs the skin barrier, maintains skin integrity and appearance, reduces transepidermal water loss, and restores the lipid barrier's ability to attract, hold, and redistribute water [28] [ Table 5]. Data from RCTs show that moisturizers have a long-and short-term steroid-sparing effect in mild to moderate AD and in preventing AD flares. ...Similar publications
Introduction:
Atopic dermatitis (AD) therapeutic approach calls for a long term treatment. Treatment options for AD have recently undergone a revolutionary change by the introduction of the first biologic drug. Availability in daily practice of the last version of international AD guidelines, taking peculiarities of the country into account, can c...
Citations
... Indian guidelines recommend cyclosporine at 3-5 mg/kg for severe AD. However, safe and effective alternative options remain limited when cyclosporine fails or is contraindicated [2,3]. ...
Atopic dermatitis (AD) is a chronic inflammatory skin disorder that profoundly affects quality of life, particularly in patients with moderate-to-severe disease that is refractory to conventional treatments.
Cyclosporine is a cornerstone of systemic therapy for severe AD; however, its long-term use is hindered by toxicity, and effective alternatives are often unavailable or insufficient. Janus kinase inhibitors, including baricitinib, have emerged as promising therapeutic options by modulating key inflammatory pathways involved in AD pathogenesis. This report describes two cases of severe cyclosporine-refractory AD that were successfully managed with baricitinib. Both patients showed substantial clinical improvement, including significant reductions in affected body surface area, disease severity scores, pruritus, and sleep disturbances
within four weeks of initiating treatment. No serious adverse effects were observed, and the treatment was well tolerated. These findings highlight the potential of baricitinib as a viable therapeutic alternative for severe AD, particularly in settings where biologics such as dupilumab or abrocitinib may be limited. While
baricitinib demonstrates both rapid and sustained efficacy, further studies are warranted to confirm its longterm safety and define its optimal role in AD management.
... Twenty-eight guideline documents were located from 2005-2021. Of these, 17 were guidelines, [15][16][17][18][19]22,23,25,26,28,29,31,32,[35][36][37][38][39]41,44,47,48 7 were consensus documents, 20,21,24,34,40,42,43,46 2 were position papers, 27,45 1 was a clinical report, 30 and 1 was an expert statement. 33 Five documents were for children only, and the remaining 23 were for adults and children. ...
... Recommendations from the guidelines published from 2018 to 2023 are summarized below and in Tables 2 and 3. General skin care measures All 12 guidelines from 2018 to 2023 recommended liberal emollient use after bathing. 17,19,[37][38][39][40][41][42][43][44][45][46][47][48] The type of emollient depends on patient preference; however 1 guideline recommended traditional emollients like coconut oil, 37 whereas 2 others found this increased xerosis. 38,39,42,43 Bathing was discussed in all guidelines, with some specifying lukewarm water for 5-10 min. ...
... 38,39,41 Topical calcineurin inhibitors were indicated in all guidelines for second line use in acute flares, or first line for sensitive areas like the face, anogenital region, and skin folds; however only 3/12 recommended the use in under 2 years of age. 38,39,44,45 Proactive use was also supported in 10/12 guidelines. 17,19,38,39,[41][42][43][44][45][46][47][48] Wet wrap therapy (wet dressings) was recommended in 10/ 12 guidelines, mostly for short-term use in severe refractory cases. ...
Atopic dermatitis (AD) is a chronic disease that is increasing in prevalence, particularly in children and people with skin of colour. Current management involves topical treatments, phototherapy and immunosuppressants, as well as newer therapies like dupilumab. Health professionals should also be aware of the specific management considerations for AD in people with skin of colour. This systematic review was conducted to examine global guidelines for the management of AD in children, compare management recommendations, examine specific recommendations for children with skin of colour, and assess the quality of the guidelines.
The databases Medline, Embase, CINAHL, Scopus, Guidelines International Network, and Emcare Nursing and Allied Health were searched to identify guidelines or articles relating to the management of AD in children from 1990 to 2023. A grey literature search was also undertaken. The recommendations from the guidelines were extracted and compared, and the quality of the guidelines was assessed using the Appraisal Guidelines for Research and Evaluation (AGREE) II tool.
A total of 1644 articles were identified from the initial search. Title and abstract screening, full text screening, and reference checking yielded 28 guidelines for the final appraisal and data extraction. The main variations in management recommendations were the timing of emollients, bleach baths, bath additives, oral antihistamines, and the age cut-offs for topical calcineurin inhibitors. Many guidelines were not updated to reflect newer therapies like dupilumab and topical phosphodiesterase-4 (PDE4) inhibitors. There were minimal recommendations regarding management of skin of colour. Only 12/28 guidelines met the satisfactory cut-off score for the AGREE II appraisal, largely due to a lack of well-documented methodology.
This review showed that the recommendations for AD management in skin of colour were consistently lacking. Despite generally consistent management strategies over the last 5 years, less than half of the guidelines met high-quality criteria, emphasising the importance of using tools like AGREE II in future guideline development.
... Dermatol Ther (Heidelb) The management practice of AD varies across Asian countries and territories (Table S1), including Hong Kong, India, Indonesia, Malaysia, Philippines, Singapore, Taiwan, Thailand, and Vietnam. When managing patients with moderate-to-severe AD, countries tend to follow their own national guidelines [6,[13][14][15][16][17][18][19]. In geographically diverse India, hospitals across the country even developed individualized guidelines in response to the different setting-specific management approaches used. ...
... In geographically diverse India, hospitals across the country even developed individualized guidelines in response to the different setting-specific management approaches used. However, existing national AD guidelines, along with previously developed regional consensus, have largely excluded recommendations on advanced novel treatments such as biologics and Janus kinase (JAK) inhibitors, as they were authored prior to the availability of these newer treatment options in the region [6,[13][14][15][16][17]20]. Consequently, physicians in these Asian countries may over-rely on nonregion specific disease management recommendations (such as those described in the 2022 EuroGuiDerm AD guidelines) to manage patients with AD, even though, ideally, treatment choices should take into consideration the barriers and limitations faced by patients in these countries [21,22]. ...
... When used for acute AD, the use of UVA1 has been shown to reduce SCORAD scores after 3 weeks of treatment, with results being evident after the first week of treatment [94,95]. Meanwhile, narrowband UVB (NB-UVB) was found to reduce total disease activity, extent of dermatitis, Dermatol Ther (Heidelb) Adults • Short-term treatment for acute flares [15,16] • To bridge treatments [15,75] • The next treatment option after failure with topical treatments [14,20] • An adjunct therapy to control itch [22] • For people with comorbidities and are not suitable for conventional DMARDs • A third-line treatment option [14,15], starting with the following priorities: CsA > AZA or MTX > MMF [15][16][17] CsA is recommended in young and fit patients [15][16][17]. In case of contraindications or treatment failure, physicians should then consider azathioprine or methotrexate, followed by MMF [15][16][17] c Owing to cost considerations d Baricitinib may be considered in patients with noncontraindicated comorbidities owing to its lower efficacy rates in clinical trials [82][83][84] e This practice is common in Singapore. ...
Rapid progress made in the management of atopic dermatitis (AD) in recent years and the differences in patient journey between Asian and non-Asian populations call for a review of current atopic dermatitis landscape in Asia.
A roundtable meeting with nine regional dermatological experts was held in June 2023 to discuss the optimal management approaches for moderate-to-severe AD, focusing on the use of advanced therapies.
Disease burden on patients’ quality of life, treatment adherence, and financial constraints were identified as major concerns when managing patients with moderate-to-severe AD in parts of Asia. It was agreed that the Hanifin and Rajka’s criteria or the UK Working Party’s Diagnostic Criteria for Atopic Dermatitis can be used to guide the clinical diagnosis of AD. Meanwhile, patient-reported outcome scales including the Dermatology Life Quality Index and Atopic Dermatitis Control Tool can be used alongside depression monitoring scales to monitor treatment outcomes in patients with AD, allowing a better understanding for individualized treatment. When managing moderate-to-severe AD, phototherapy should be attempted after failure with topical treatments, followed by conventional disease-modifying antirheumatic drugs and, subsequently, biologics or Janus kinase inhibitors. Systemic corticosteroids can be used as short-term therapy for acute flares. Although these advanced treatments are known to be effective, physicians have to take into consideration safety concerns and limitations when prescribing these treatments.
Treatments in AD have evolved and its management varies country by country. Unique challenges across Asian countries necessitate a different management approach in Asian patients with AD.
... [4] Emollients, topical corticosteroids, topical calcineurin inhibitors, and phototherapy are the mainstays of treatment for AD; however, moderate to severe AD is frequently resistant to these treatments. [5] Although immunomodulatory drugs (such as cyclosporine, methotrexate, and azathioprine) had been tried in refractory AD with varying degrees of effectiveness, a better understanding of the pathogenesis has opened the door to the prospect of the novel, targeted therapies. [6] In various inflammatory skin conditions, including AD, the JAK inhibitors have been explored and proven to be beneficial. ...
... Cyclosporine, azathioprine, and methotrexate are some of the other systemic treatments that have been suggested in the Indian context. [5] The US FDA has approved dupilumab as the first targeted biologic medication for the treatment of adults with moderate to severe AD. The authors have published the first reports from India, where dupilumab was successfully used to treat 25 adult patients with AD. [6] However, due to its high price and limited availability, the use of dupilumab in patients with refractory AD in India has remained out of reach for most patients who actually need it. ...
Background
Atopic dermatitis (AD) has a complex etiology that includes Th2 polarization, which is accompanied by the cytokines IL4, IL-5, IL-13, and IL-31, as well as Th17 and Th22, and in chronic lesions, Th1 cells. Tofacitinib inhibits Th1-, Th2-, and Th17-associated cytokines by selectively blocking JAK1 and JAK3 receptors. We conducted a multicentric, retrospective chart analysis to study the efficacy and safety of tofacitinib in patients with moderate to severe refractory AD.
Materials and Methods
We included 16 adult patients (aged >18 years) with moderate to severe AD who had previously undergone systemic therapy with inadequate response. In the baseline, demographic data, previous treatment history, severity scores (eczema area and severity index [EASI] and SCORing Atopic Dermatitis [SCORAD]), and quality of life score (Dermatology Life Quality Index [DLQI]) were noted. Baseline blood investigations, including complete blood count, liver function test, renal function test, lipid profile, and interferon gamma release assay for tuberculosis, were done. Patients were followed up every month for 6 months that included documentation of severity scores, blood investigations, and DLQI. Any adverse events, if reported, were noted.
Result
All 16 patients completed the 6-month trial. Our patients were previously treated with cyclosporine (n = 10), methotrexate (n = 3), or both (n = 3). The mean EASI scores improved from 23.38 ± 9.56 at baseline to 8.50 ± 7.57 at the end of 6 months. The mean SCORAD score improved from 41.25 ± 8.69 at baseline to 14.93 ± 7.82 at the end of 6 months. Quality of life also improved as the mean DLQI improved from 15.18 ± 2.73 at baseline to 5.31 ± 4.11 at the end of the study period. No severe adverse reactions were noted, but 3 patients experienced dyslipidemia and 2 patients had altered bleeding time.
Conclusion
Tofacitinib is a safe and effective treatment option for recalcitrant moderate to severe adult AD.
... It is based on the Indian and European guidelines. [81][82][83] ...
Atopic dermatitis (AD) a chronically relapsing dermatosis characterized by pruritus and a significant impact on the quality of life. Emollient and moisturizers are an integral part of its management and those containing natural moisturizing factors (NMF) and pseudoceramides are known to be efficacious barrier repair agents. Conventionally topical corticosteroids (TCS) and topical calcineurin inhibitors (TCI) are considered as the mainstay of treatment. Systemic medications such as azathioprine, cyclosporine and methotrexate may be associated with substantial side effects, with long-term usage. Novel therapeutic agents such as Janus kinase (JAK) inhibitors, subcutaneous monoclonal antibodies and topical PDE4 inhibitors targeting the complex pathophysiology have been recently developed. Dupilumab is a subcutaneous monoclonal antibody and is FDA approved. Amongst the newer topicals, Crisaborole ointment is found to be potentially effective and is FDA approved. Only dupilumab and crisaborole have been successfully marketed for patients <18 years of age.
... 1 It is characterized by recurrent eczematous lesions 1 , and intense itch 1 and is often associated with elevated serum immunoglobulin E (IgE) levels. 2 It affects up to approximately 2.4% of the population worldwide 3 and can also appear in adults. 1 Onset of AD usually presents by the age of five years, but timely diagnosis and treatment will avoid future complications and improve patients' quality of life. 4 As per the International Study of Asthma and Allergies in Childhood (ISAAC), the prevalence of atopic dermatitis in India is 2.7% (age 6-7 years) and 3.6% (age 13-14 years). ...
... 6 Emollients remain the mainstay treatment for atopic dermatitis as they improve the epidermal barrier function, maintain skin integrity and appearance, reduce trans epidermal water loss, and restore the lipid barrier's ability to attract, hold, and redistribute water. 2 The Indian guidelines also recommend the use of Moisturizers & Emollients as a firstline treatment for AD. 2 Emollients contain a humectant or moisturizer (promoting stratum corneum hydration) and an occludent (reducing evaporation such as lipids or petrolatum). Emollients containing moisturizers are better compared to those without, for reducing investigator-reported severity and leading to fewer flares and reduced usage of topical corticosteroids (TCS). ...
... 6 Emollients remain the mainstay treatment for atopic dermatitis as they improve the epidermal barrier function, maintain skin integrity and appearance, reduce trans epidermal water loss, and restore the lipid barrier's ability to attract, hold, and redistribute water. 2 The Indian guidelines also recommend the use of Moisturizers & Emollients as a firstline treatment for AD. 2 Emollients contain a humectant or moisturizer (promoting stratum corneum hydration) and an occludent (reducing evaporation such as lipids or petrolatum). Emollients containing moisturizers are better compared to those without, for reducing investigator-reported severity and leading to fewer flares and reduced usage of topical corticosteroids (TCS). ...
The prevalence of atopic dermatitis (AD) in India is 2.7% (age 6–7 years) and 3.6% (age 13–14 years). Emollients remain mainstay treatment for atopic dermatitis. The present review article focuses on the role of active ingredients in emollients towards the management of AD. Article were selected by searching in database like Google Scholar and PubMed and were reviewed by the authors. Daily use of emollients from birth may significantly reduce the incidence of AD in a high-risk population. Emollients with a variety of active ingredients to target AD pathophysiology have been developed which contain active ingredients like liquorice extract (anti-inflammatory and anti-pruritic), niacinamide (restoration of barrier function), sterols (restoration of barrier function), laureth-9-polydocanol (anti-pruritic), xylitol (microbiome maintenance) and galacto-oligosaccharide (GOS) (microbiome maintenance). Emollient plus may be a useful adjunct to pharmacological therapy in AD and as maintenance therapy, providing rapid and significant improvements in skin moisture, epidermal barrier function, and signs and symptoms of AD.
... ,21 . U Hrvatskoj nisu dostupni TKS I. i IV. kategorije, dok dostupni betametazon, prednizolon i metilprednizolon pripadaju u jake, a mometazon i alklometazon u umjereno jake. ...
Psorijaza je imunološki posredovana kronična upalna bolest kože i zglobova. Najčešći oblik psorijaze jest vulgarna ili kronična stacionarna psorijaza, a očituje se pojavom eritematoznih plakova prekrivenih srebrnkastim ljuskama, praćenih svrbežom. Rjeđi oblici psorijaze jesu kapljičasta, eritrodermijska i pustulozna psorijaza te psorijaza praćena psorijatičnim artritisom. Procjena težine bolesti vrši se pomoću kliničkih bodovnih sustava, a važna je zbog odabira prikladne terapije. Prvu liniju liječenja blage do srednje teške psorijaze čini lokalna terapija, dok je kod težih oblika bolesti te pacijenata koji nemaju adekvatan odgovor na lokalnu terapiju ili fototerapiju, indicirana sustavna terapija. Postoji mogućnost kombiniranja lokalne i sustavne terapije, a u određenim slučajevima i fototerapije. U skladu sa smjernicama Hrvatskog dermatovenerološkog društva prva linija lokalnog liječenja psorijaze jest fiksna kombinacija kalcipotriola i betametazon propionata jednom dnevno uz mogućnost proaktivnog liječenja dva puta tjedno. U terapiji održavanja prvenstveno se preporučuje fiksna kombinacija kalcipotriola i betametazon propionata jednom ili dva puta tjedno. U slučaju psorijaze lica i intertriginoznih regija preporučuje se započeti liječenje lokalnim kortikosteroidima, a potom nastaviti s lokalnim inhibitorima kalcineurina. Lokalni pripravci u liječenju psorijaze neizostavan su dio liječenja blage do srednje teške psorijaze, ali i potpora liječenju težih oblika psorijaze uz sustavnu terapiju.
... 4 Atopic dermatitis is a potential contributor to cause debilitating symptoms, and it significantly reduces the patient's quality of life. 5,6 Due to the heterogeneity in age, ethnicity, and lifestyle factors of patients, the etiology of atopic dermatitis has not been fully clarified. 7---9 Currently, topical application of emollients and anti-inflammation agents is still the basic strategy for treating atopic dermatitis. ...
Background
The treatment for atopic dermatitis (AD) has been the focus of clinical research, and behavioral intervention is considered an indispensable treatment method. To our knowledge, no relevant meta-analysis has evaluated the effects of behavioral interventions on atopic dermatitis.
Objectives
To evaluate the effects of behavioral interventions on atopic dermatitis.
Methods
The authors searched PubMed, EMBASE, and Cochrane CENTRAL to retrieve relevant RCTs (up to Feb 2022). The search strategy involved a combination of related keywords. The Cochrane Q and I² statistics were used to assess heterogeneity.
Results
Six RCTs involving seven reports with 246 patients were included. The results suggested that behavioral interventions could relieve eczema severity (correlation coefficient [r = −0.39]; p < 0.001) and scratching severity significantly (r = −0.19; p = 0.017), while not affect itching intensity (r = −0.02; p = 0.840). A sensitivity analysis confirmed the robustness of the results.
Study limitations
An important limitation of this study was the insufficient number of RCTs and the limited sample size. In addition, the study lacked a control group receiving a type of intervention other than the experimental protocol. Another limitation was the short duration of follow-up.
Conclusions
This study suggests that behavioral interventions could be effective in treating atopic dermatitis by reducing eczema and scratching severity. Additionally, habit-reversal behavioral therapy may be more effective for treating atopic dermatitis.
... Pityriasis alba was the third most common among the eczemas in our study, whereas it was <2% in the studies done in Iraq and Ethiopia. This might be because pityriasis alba [43] is common in higher skin phototypes (Indian) with prolonged sun exposure and dry skin as additional risk factors in desert regions. ...
... Hence, it needs increased patient education. [3] Phosphodiesterase 4 (PDE4) regulates inflammatory cytokine production in AD by degrading cyclic adenosine monophosphate (cAMP). Inflammatory cells in AD patients have higher PDE4 *Corresponding author: Abhishek De, Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India. ...
Objectives
Managing mild-to-moderate atopic dermatitis (AD) often necessitates topical therapies, and one such recently introduced option is crisaborole ointment. This study sets out to assess the efficacy and safety of crisaborole ointment in pediatric cases of AD over four weeks.
Material and Methods
Nineteen children between 2 and 16 years old with mild-to-moderate AD were enrolled and treated with crisaborole ointment twice daily in affected areas for 30 days. The primary objective was to appraise the shift in the investigator’s static global assessment (ISGA) scores (0–4) every week for the four-week follow-up. The severity of pruritus score (SPS) was another secondary objective. Furthermore, individual indicators of clinical signs that included erythema, exudation, excoriation, induration/papulation, and lichenification, were examined with subjective scores (0–3). Children’s dermatology quality of life index (CDLQI) was employed to study the quality of life.
Results
Following four weeks of crisaborole ointment treatment, the average ISGA score declined from 2.58 ± 0.61 to 0.95 ± 0.78, signifying a substantial reduction in AD severity ( P < 0.001). The SPS score also decreased from a mean of 2.32 ± 0.478 to 0.84 ± 0.60 ( P < 0.001), underscoring a significant reduction in itching. Moreover, individual markers for clinical signs of AD, including erythema, exudation, excoriation, induration/papulation, and lichenification, all exhibited statistically significant improvement. Crisaborole ointment was well tolerated. Only 6 of the 19 patients reported a localized burning sensation, which was manageable. No patient needed to be withdrawn during the study period. The CDLQI showed a substantial drop in scores, decreasing from an average of 13.79 ± 3.57 at the commencement to 6.74 ± 1.97 ( P < 0.001). Furthermore, 14 out of 19 patients met the study’s primary goal, achieving at least a 2-point reduction in ISGA along with the attainment of clear or nearly clear skin (ISGA 0–1).
Conclusion
Our study found crisaborole ointment significantly improved pediatric AD symptoms and was well-tolerated. The only adverse event was localized burning in a few patients. Further, research is needed for validation.
