A systematic review of guidelines for the management of atopic dermatitis in children

Abstract

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.

Full text

REVIEW Open Access
A systematic review of guidelines for the
management of atopic dermatitis in children
Maya Deva, MBBS
a
, Merryn J. Netting, PhD
b
, Jemma Weidinger, MN, NP
c
, Roland Brand, FACD
c
,
Richard KS. Loh, FRACP
d
and Sandra L. Vale, PhD
b
*
ABSTRACT
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 chil-
dren 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 man-
agement 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 man-
agement 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.
Keywords: Atopic dermatitis, Eczema, Guidelines
a
James Cook University, 1 James Cook Drive, Douglas, QLD, 4814, Australia
*Corresponding author. National Allergy Council, PO Box 367, Guildford,
WA 6055, Australia. E-mail: sandravale@iinet.net.au
Full list of author information is available at the end of the article
http://doi.org/10.1016/j.waojou.2024.100989
Received 29 April 2024; Received in revised from 10 September 2024;
Accepted 10 October 2024
Online publication date xxx
1939-4551/© 2024 The Author(s). Published by Elsevier Inc. on behalf of
World Allergy Organization. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

INTRODUCTION
Atopic dermatitis (AD) is a chronic, inflammatory
disease of the skin that commonly presents during
childhood. There has been an overall increase in
prevalence of this condition, and it is estimated to
affect 20% of children and 10% of adults world-
wide.
1–3
AD arises from a combination of genetic
factors, skin barrier defects, and dysregulated
immune response.
4
It is commonly the first step in
the "atopic march", with higher risks of developing
other atopic diseases like food allergies, allergic
rhinitis, and asthma. Although not life threatening,
AD poses significant health risks including
secondary bacterial or viral infections and
potentially more severe food allergic reactions, and
it greatly impacts quality of life through decreased
sleep, productivity, behavioural issues, low self-
esteem, anxiety, depression, and stress on
caregivers.
5
The mainstay of management for AD has not
changed significantly over the last 20 years, with
key aspects involving emollient use, bathing,
topical steroids, topical calcineurin inhibitors, wet
dressings, phototherapy, and immunosuppres-
sants. In the last 5 years, however, biologics such
as dupilumab have changed the landscape of AD
management, decreasing the need for systemic
immunosuppressants and with a minimal side-
effect profile. These management options are re-
flected in the different guidelines, as well as other
aspects of management like environmental modi-
fication, psychological support, and educational
interventions. Managing AD in children with skin of
colour has become increasingly important with AD
becoming more common in these patients.
6
Skin
of colour refers to the increased melanin and
darker pigmentation found in many different
ethnic groups such as Asian, African, Middle
Eastern, Latin, and First Nations Peoples.
7–9
As guidelines underpin evidence-based medici-
nal practice, it is important to ensure that these
documents correspond with the best management
recommendations and abide by a transparent,
robust development processes.
10
A commonly used
tool to appraise guideline quality is the Appraisal
Guidelines for Research and Evaluation (AGREE II)
standardised guideline appraisal tool. This tool has
been shown to successfully identify high quality
guidelines using a twenty-three-item questionnaire
that reviewers use to rate aspects of the guidelines on
a scale of 1–7 (7 being the highest).
11
This systematic review examined the existing
guidelines regarding the management of AD in
the paediatric population globally. The term
guideline refers to all documents that contain
recommendations for clinical practice or health
policy as outlined by the World Health Organiza-
tion (WHO), and includes evidence-based guide-
lines, expert recommendations, protocols, and
consensus statements.
12
The 3 main goals of the analysis were: 1) to
compare management strategies in the guidelines
for AD in children, 2) to determine whether specific
reference is made to managing AD in children with
skin of colour, and 3) to assess the quality of the
guidelines using the AGREE II standardised
guideline appraisal tool.
13
METHODS
Search strategy
Systematic search methods were used to iden-
tify relevant guidelines. The initial search was per-
formed on the databases Medline, Embase,
CINAHL, Scopus, Guidelines International
Network, and Emcare Nursing and Allied Health.
Guideline documents addressing the manage-
ment of AD in children (birth to 18 years) were
included. The search was limited to articles pub-
lished from 1990 to 2023, referenced children
(from birth-18 years of age), and were in English.
The following search terms were used: (child OR
infant OR toddler OR paediatric OR minor OR
baby OR teenager OR adolescent OR "young
person" OR "young people") AND (eczema OR
"atopic dermatitis" OR "atopic eczema") AND
(guideline OR strategy OR policy OR statement OR
protocol OR recommendation OR consensus OR
"clinical practice") AND ("health professionals" OR
"general practitioner" OR nurse OR paediatrician
OR doctor OR "medical practitioner"). A grey
literature search was also undertaken. This yielded
a total of 1644 articles for title and abstract
screening once duplicates were removed.
Article screening
Two independent reviewers screened the arti-
cles. The first stage involved title and abstract
2Deva et al. World Allergy Organization Journal (2024) 17:100989
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screening, resulting in 189 included articles. After
full text screening, 114 were selected with rea-
sons for exclusion listed in Fig. 1.Thesecond
stage involved extracting details about any
guideline documents mentioned in the full texts
(either from the text itself or the reference list).
This resulted in 176 potential guideline
documents. After another full text screen, the
reviewers decided to exclude any guidelines
that were not specifically about AD (for example
those that were about food allergies), and those
relating to only 1 aspect of management. To
reflect nation-wide practices, guidelines owned
by individuals were excluded. A total of 58
guidelines remained, however only 28 were
included in the final appraisal and data extraction.
Twenty outdated versions of guidelines were
excluded, as updated versions were available,
and 4 articles were excluded as they were not
considered guidelines. Guidelines that had been
published in several sections were combined for
appraisal.
Fig. 1 PRISMA flowchart.
Volume 17, No. 12, Month 2024 3

Guideline comparison
Descriptive data including the title, organisa-
tion, year of development, region developed, and
type of document was extracted. The recommen-
dations from each guideline regarding specific
aspects of management and whether the guide-
lines made a specific reference to managing skin
of colour were summarized.
Quality appraisal
The guidelines identified were appraised using
the AGREE II tool.
13
The tool outlines 23 criteria
under 6 domains that can be used to assess
guideline quality, which include: scope/purpose
(objectives, question, population); stakeholder
involvement (group membership, target
population, target users); rigor of development
(search methods, evidence criteria, evidence
strengths and limitations, recommendations,
benefits and harms considerations,
recommendations and evidence link, external
review, updating procedures); presentation
clarity (specific, unambiguous recommendations,
management options, identifiable key
recommendations); applicability (application
facilitators and barriers, implementation of
advice/tools, resource implications, monitor/
audit criteria); and editorial independence
(funding body, competing interests).
Guidelines were given a score from 1 to 7 by
each reviewer (7 being the best) for the 23 criteria.
A score of 1 was given either when the criteria was
not met, or that section was missing from the
guideline, ie, no funding statement provided. After
scoring independently, the reviewers discussed
any large differences (>4 points) to resolve major
discrepancies or errors during scoring. Domain
scores were then calculated using the formula:
A higher AGREE II score is likely to be achieved
by having a well-documented, robust develop-
ment process as this ensures guidelines have a
high-quality evidence base and the process un-
derpinning recommendations is clear. Therefore,
the domain cut-off scores for a high-quality
guideline were set to include at least 50% in the
"Rigor of Development" domain and at least 2
other domains, which is consistent with previously
published use of the AGREE II tool.
14
RESULTS
Overview of guidelines
Twenty-eight guideline documents were located
from 2005-2021.
15–48
Of these, 17 were
guidelines,
15–19,22,23,25,26,28,29,31,32,35–39,41,44,47,48
7 were consensus documents,
20,21,24,34,40,42,43,46
2werepositionpapers,
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. In
terms of geographical location, 11 were
developedinAsia,8inEurope,4inNorth
America, 2 in South America, 2 in Africa, and 1
joint in Europe and the United States. A list of
these guidelines can be seen in Table 1.
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 recom-
mended liberal emollient use after bathing.
17,19,37–
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.
38–40,42–47
There were differing recommendations for bath
additives, with 6/12 guidelines recommending
bleach baths,
17,19,38–40,46,47
and 4/12
recommending bath oils.
38–41
Furthermore, 10/12
guidelines recommended cleansing with soap
free, neutral pH, hypoallergenic cleansers.
37–48
obtained domain score minimum possible domain score
maximum possible domain score minimum possible domain score 100%
4Deva et al. World Allergy Organization Journal (2024) 17:100989
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Guideline Organisation Name of document Type of
document Region Year Target
1 Allergy Society of South
Africa Childhood Atopic
Eczema Consensus
Document
20
Consensus
document South
Africa 2005 Children
2 European Academy of
Allergology and Clinical
Immunology/American
Academy of Allergy,
Asthma and
Immunology/PRACTALL
Diagnosis and
treatment of atopic
dermatitis in children
and adults: European
Academy of Allergology
and Clinical
Immunology/American
Academy of Allergy,
Asthma and
Immunology/PRACTALL
Consensus Report
21
Consensus
document Europe/
United
States
2006 Children
and adults
3 Dermatological,
Paediatric (SAPA) and
Allergy (ALLSA)
Societies of South Africa
Guidelines on the
management of atopic
dermatitis in South
Africa
15
Guideline South
Africa 2008 Children
and adults
4 Primary Care
Dermatology Society/
Scottish Intercollegiate
Guidelines network
Management of Atopic
Eczema in Primary Care:
A national clinical
guideline
18
Guideline Scotland 2011 Children
and adults
5 American Academy of
Allergy, Asthma and
Immunology, American
College of Allergy,
Asthma & Immunology
(ACAAI); and the Joint
Council of Allergy,
Asthma and
Immunology
Atopic dermatitis: a
practice parameter
update 2012
24
Consensus
document United
States 2012 Children
and adults
6 Hong Kong College of
Paediatricians Clinical guidelines on
management of atopic
dermatitis in children
22
Guideline Hong
Kong 2012 Children
(continued)
Volume 17, No. 12, Month 2024 5

Guideline Organisation Name of document Type of
document Region Year Target
8 Asia-Pacific Consensus
Group for Atopic
Dermatitis
Consensus guidelines
for the management of
atopic dermatitis - an
Asia-Pacific
perspective
23
Guideline Asia-
Pacific2013 Children
and adults
7 National Institute for
Health and Care
Excellence (NICE)
Atopic eczema in under
12s
16
Guideline UK 2013 Children
9 American Academy of
Paediatrics Clinical report on atopic
dermatitis - skin-
directed
management
30
Clinical
report United
States 2014 Children
10 American Academy of
Dermatology Guidelines of care for
the management of
atopic dermatitis:
Section 1. Diagnosis
and Assessment of
Atopic Dermatitis
26
Guidelines of care for
the management of
atopic dermatitis:
Section 2: Management
and Treatment of Atopic
Dermatitis with Topical
Therapies
25
Guidelines of care for
the management of
atopic dermatitis:
section 3. Management
and treatment with
phototherapy and
systemic agents
28
Guidelines of care for
the management of
atopic dermatitis:
Section 4. Prevention of
disease flares and use of
adjunctive therapies
and approaches
29
Guideline United
States 2014 Children
and adults
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11 Latin American Society
of Allergy, Asthma and
Immunology
Atopic dermatitis
guideline. Position
paper from the Latin
American Society of
Allergy, Asthma and
Immunology
27
Position
paper Latin
America 2014 Children
and adults
12 Polish society of
allergology, and the
allergology section,
Polish society of
dermatology
Atopic dermatitis:
current treatment
guidelines. Statement of
the experts of the
dermatological section,
Polish society of
allergology, and the
allergology section,
Polish society of
dermatology
33
Expert
statement Poland 2015 Children
and adults
13 Korean Atopic
Dermatitis Association Consensus guidelines
for the treatment of
atopic dermatitis in
Korea (Part I): general
management and
topical treatment
32
Consensus guidelines
for the treatment of
atopic dermatitis in
Korea (Part II): Systemic
Treatment
31
Guideline Korea 2015 Children
and adults
14 Italian Society of
Paediatric Allergology
and Immunology (SIAIP)
and the Italian Society of
Paediatric Dermatology
(SIDerP)
Consensus Conference
on Clinical Management
of paediatric Atopic
Dermatitis
34
Consensus
document Italy 2016 Children
15 German Dermatological
Society S2k guideline on
diagnosis and treatment
of atopic dermatitis—
Short version
36
Guideline Germany 2016 Children
and adults
16 Dermatological Society
of Singapore Guidelines for the
management of atopic
dermatitis in
Singapore
35
Guideline Singapore 2016 Children
and adults
(continued)
Volume 17, No. 12, Month 2024 7

Guideline Organisation Name of document Type of
document Region Year Target
17 Asian Academy of
Dermatology and
Venereology Expert
Panel on Atopic
Dermatitis
A clinician’s reference
guide for the
management of atopic
dermatitis in Asians
37
Guideline Asia 2018 Children
and adults
18 European Dermatology
Forum (EDF), European
Academy of
Dermatology and
Venereology (EADV),
European Academy of
Allergy and Clinical
Immunology (EAACI),
European Task Force on
Atopic Dermatitis
(ETFAD), European
Federation of Allergy
and Airways Diseases
Patients’Associations
(EFA), European Society
for Dermatology and
Psychiatry (ESDaP),
European Society of
Pediatric Dermatology
(ESPD), Global Allergy
and Asthma European
Network (GA2LEN), and
European Union of
Medical Specialists
(UEMS)
Consensus-based
European guidelines for
treatment of atopic
eczema (atopic
dermatitis) in adults and
children: part I
39
Consensus-based
European guidelines for
treatment of atopic
eczema (atopic
dermatitis) in adults and
children: part II
38
Guideline Europe 2018 Children
and adults
19 Ministry of Health
Malaysia Management of Atopic
Eczema
17
Guideline Malaysia 2018 Children
and adults
20 Turkish Society of
Dermatology Turkish Guideline for
Atopic Dermatitis
2018
19
Guideline Turkey 2018 Children
and adults
21 European Task Force on
Atopic Dermatitis/
European Academy of
Dermatology and
Venereology
Position paper of the
diagnosis and treatment
of atopic dermatitis in
adults and children
45
Position
paper Europe 2018 Children
and adults
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23 Brazilian Society of
Dermatology Consensus on the
therapeutic
management of atopic
dermatitis - Brazilian
Society of
Dermatology
40
Consensus
document Brazil 2019 Children
and adults
22 Canadian Dermatology
Association Approach to the
Assessment and
Management of
Pediatric Patients With
Atopic Dermatitis: A
Consensus Document.
Section 3
42
Approach to the
Assessment and
Management of
Pediatric Patients With
Atopic Dermatitis: A
Consensus Document.
Section 4
43
Consensus
document Canada 2019 Children
24 Indian Dermatology
Expert Board Members Guidelines on
Management of Atopic
Dermatitis in India: An
Evidence –based Review
and an Expert
Consensus
44
Guideline India 2019 Children
and adults
25 Italian Society of
Medical, Surgical and
Aesthetic Dermatology
and Venereology
(SIDEMAST), Italian
Society of
Dermatologists and
Venereologists Hospital-
based and Public Health
(ADOI), and Italian
Society of Allergological
Occupational and
Environmental
Dermatology (SIDAPA)
Italian guidelines for
therapy of atopic
dermatitis—Adapted
from consensus-based
European guidelines for
treatment of atopic
eczema (atopic
dermatitis)
41
Guideline Italy 2019 Children
and adults
(continued)
Volume 17, No. 12, Month 2024 9

Guideline Organisation Name of document Type of
document Region Year Target
26 Taiwanese
dermatological
association
Taiwanese
Dermatological
Association
consensus for the
management of atopic
dermatitis: A 2020
update
46
Consensus
document Taiwan 2020 Children
and adults
27 Chinese Society of
Dermatology
Immunology
Guidelines for the
diagnosis and treatment
of atopic dermatitis in
China
47
Guideline China 2020 Children
and adults
28 Japanese
Dermatological
Association
English Version of
Clinical practice
guidelines for the
Management of Atopic
Dermatitis 2021
48
Guideline Japan 2021 Children
and adults
Table 1. (Continued) Overview of guideline documents
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Topical therapy
Topical steroids were indicated in acute flares,
with the minimum dose possible in all guide-
lines.
17,19,37–48
With regards to dosage, 4/12
guidelines recommended the fingertip
unit,
17,37,42–44
3/12 used grams,
19,40,45
and 5/12
used the site and size of the lesions.
38,39,41,46–48
One guideline recommended using topical
therapies prior to emollients
42,43
while another
recommended 15 minutes after emollients.
45
Twice weekly proactive use for remission was
recommended in 9/12 guidelines,
19,38–41,44–48
2
of which specified a duration of 20 weeks.
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.
17,19,38,39,41–48
Wet wrap
therapy (wet dressings) was recommended in 10/
12 guidelines, mostly for short-term use in severe
refractory cases.
17,19,37–40,42–45,47,48
Topical
Phosphodiesterase-4 (PDE4) inhibitors were rec-
ommended in 4/12 guidelines for children 2 years
and over.
38,39,42–44,47
The Turkish guidelines also
recommended topical coal tar preparations in
children.
19
Systemic therapy
All guidelines supported the use of narrow band
Ultraviolet B (UVB) for chronic AD.
17,19,37–48
UVA1
was recommended for acute flares in 10/12
guidelines.
17,19,37–41,44,45,47,48
One guideline
discussed the use of psoralen plus ultraviolet-A ra-
diation (PUVA) for lichenification in stable disease.
37
In all guidelines, oral prednisone was
recommended in acute flares for short term use.
Cyclosporine was the first-line long term therapy,
followed by methotrexate or azathioprine.
17,19,37–48
Furthermore, 8/12 guidelines also recommended
mycophenolate mofetil as a third-line option for off
label use in children.
17,19,37–39,41–43,45,46
If using
systemic therapies in children under 2 years,
specialist input was advised in 2/12
guidelines.
40,45
Systemic immunosuppressants
were not approved for paediatric patients in the
Japanese guidelines.
48
Dupilumab was
recommended for use in children 12 years and
older in 4/12 guidelines.
38,39,42,43,45,46
While 1/12
guidelines did not specify a minimum age for
use.
48
The remaining 6/12 guidelines only
supported dupilumab use in
adults.
17,19,37,40,41,44,46
Other biologics
recommended for trial in severe cases include
mepolizumab
38,39
and baricitinib.
48
Managing infections
For staphylococcus aureus bacterial infections,
all guidelines recommended a short course of
systemic or topical antibiotics depending on the
lesions. Systemic antivirals were advised for
eczema herpeticum. For head and neck AD with
known Malassezia colonisation, topical or systemic
antifungals can be used.
17,19,37–48
Short term
topical antiseptics were recommended for
bacterial infections in 5/12 guidelines,
19,38–41,45
1 of which also recommended long term use in
chronic treatment resistant AD.
38,39
Pruritis control
There was differing recommendations
regarding antihistamine use for pruritis control.
While 11/12 guidelines supported the short-term
use of sedating antihistamines,
17,19,37–41,44–48
3/
12 guidelines advised non-sedating antihista-
mines could be used in a subset of patients with
allergic rhinitis, urticaria, bronchial asthma or der-
mographism.
45–47
Other therapies included
melatonin in the Taiwanese guideline
46
and
mirtazapine, pregabalin, paroxetine or naltrexone
in the Chinese guidelines.
47
Dietary measures
The Chinese guideline recommended trialling
diagnostic elimination diets for 4–6 weeks.
47
Others did not support the use of elimination
diets or supplements like probiotics or vitamin D
unless there were clinically proven allergies.
Allergy testing
One guideline advised routine allergy testing
for cow’s milk, egg, wheat, soy, and peanut al-
lergies in children under 3 with moderate-severe
AD. This guideline also recommended routinely
avoiding contact allergens like nickel, pre-
servatives, and rubber.
47
No other guidelines
recommended allergy testing unless there was
high clinical suspicion. Allergen specific
immunotherapy was recommended in 3/12
Volume 17, No. 12, Month 2024 11

guidelines for severe AD cases with allergies to
dust mite, birch, or grass pollen and a history of
exacerbation with exposure.
38,39,41,45
Patch
testing was recommended for atypical skin
lesions or triggers in 2/12 guidelines.
40,45
Other management strategies
All guidelines recommended patient and family
education, with strategies like nurse-led education
programs, videos, multidisciplinary school pro-
grams, workshops, community support groups and
written action plans.
17,19,37–48
Complementary
therapy including acupuncture, homeopathy,
aromatherapy were not recommended over
traditional therapy; however, 2/12 guidelines
supported trialling thermal spring water
38,39,41
and 1/12 trialling unsaturated fatty acid
supplements.
41
Chinese herbal medicine was
recommended in combination with traditional
measures in 2/12 guidelines.
47,48
Environmental measures like avoiding irritants
such as wool, dust mites, and occupational triggers
were discussed in 3/12 guidelines.
40,45,46
In
addition, 3/12 guidelines emphasised the
importance of routine vaccinations.
17,38,39,41
Psychological support, behavioural therapies, and
relaxation techniques were recommended when
clinically relevant in 5/12 guidelines.
38,39,41,44–46
Recommendations for skin of colour
Six guidelines commented on skin of colour to
varying degrees. The Asian Academy of Derma-
tology and Venerology guidelines discussed the
phenotypical differences between Asian and
Caucasian skin in AD.
37
The Asia–Pacific
Consensus Group for Atopic Dermatitis included
studies based on the Asia-Pacific population in the
evidence base, ensuring more targeted recom-
mendations.
23
The NICE guidelines mentioned the
different ways AD can present in Asian, Black
Caribbean, and Black African children, as well as
the difficulty of assessing severity in darker skin
tones; however, they do not suggest any other
severity scoring systems. They also mentioned
cultural sensitivity when discussing skin care
practices.
16
The Latin American guidelines
described environmental factors contributing to
AD in the region like helminth infections and the
tropical climate; however, they do not refer
specifically to skin of colour.
27
The Chinese
guidelines mentioned a diagnostic criteria that
was specifically made for paediatric Asian skin
which can help with severity assessment and
management.
47,49
The Taiwanese guideline
specified that patients and caregivers should be
educated surrounding the risk of hyper or
hypopigmentation for AD on pigmented skin.
46
These recommendations have been summarized
in Box 1.
AGREE II
Domain scores for each guideline are shown in
Table 4. Only 12/28 met the satisfactory cut-off
criteria for a high-quality guideline.
16–18,24–
29,31,32,36,38,39,41–43,48
On average, the
guidelines scored higher in Domain 1 (scope and
purpose) and Domain 4 (clarity of presentation),
with average scores of over 70%. Domain 5
Box 1. Summary of recommendations
for skin of colour extracted from
guidelines
1. There are phenotypical differences be-
tween Asian and Caucasian skin in AD, such
as a unique cytokine profiles (Asian Acad-
emy of Dermatology and Venerology)
37
2. AD can present differently in Asian, Black
Caribbean and Black African children
(Asian Academy of Dermatology and Ven-
erology and NICE)
16,37
3. There can be difficulty assessing the
severity of atopic dermatitis in darker skin
tones (NICE)
16
4. Cultural sensitivity is important when dis-
cussing skin care practices (NICE)
16
5. Specific diagnostic criteria can be used for
paediatric Asian skin, which can help with
severity assessment and management
(Chinese Society of Dermatology
Immunology)
47,49
6. Patients and caregivers should be educated
surrounding the risk of hyper or hypo-
pigmentation for atopic dermatitis on pig-
mented skin (Taiwanese Dermatological
Association)
46
12 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

Author, Title,
Year Emollients Bathing and
cleansing TCS
Topical
calcineurin
inhibitors
Wet wraps Phototherapy Immunosuppressants
Asian Academy
of Dermatology
and
Venereology
Expert Panel on
Atopic
Dermatitis,
A clinician’s
reference guide
for the
management of
atopic
dermatitis in
Asians
37
2018
Moisturisers directly
after bathing on
damp skin, 2–3 times
daily
Support the use of
traditional
emollients like
coconut oil, olive oil
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Indicated in flares,
FTU recommended.
Start with mild
potency twice/day
after bathing
Indicated when
recalcitrant to
steroids,
prolonged
uninterrupted
steroid use,
steroid atrophy
or sensitive areas
including face,
anogenital, skin
folds, paediatric,
Use twice/day
after bathing
Recommended
Can use ‘double
pyjama method’
Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares
PUVA for
lichenification,
active and
stable disease
Recommended when
refractory to
conventional therapy,
severe disease with large
body surface area,
generalised exfoliative
dermatitis
Requires dermatologist
referral. All require
monitoring bloods
Oral prednisone:
minimum duration and
dose for acute flares or
bridging therapy, 0.5–
1mg/m2/day
Cyclosporine first line.
Methotrexate
recommended for
children. Azathioprine in
older children and
teenagers, second line,
recommend checking
TMPT. Mycophenolate
mofetil third line
EDF, EADV,
EAACI, ETFAD,
EFA, ESDaP,
ESPD,
GA2LEN, and
UEMS
Consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis) in
adults and
children: part
I
39
þII
38
2018
Moisturisers directly
after bathing on
damp skin, 2–3 times
daily
Do not recommend
pure oils like
coconut oil
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,5–
10 min. Can add
bleach or bath oils
(in last 2 min)
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for 20
weeks
Avoid super potent
steroids in children
Use after topical
steroids in acute
flares and
proactively. First
line for sensitive
areas.
Pimecrolimus in
mild AD,
tacrolimus in
moderat-severe.
Can use off label
in under 2 years
Wet wrap
therapy for 14
days for severe/
refractory cases
Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares
Oral prednisone: 1 week
short term, acute flares
0.2–0.5mg/m2/day
Cyclosporine first line,
azathioprine (check
TPMT), methotrexate,
mycophenolate mofetil
can be used off label for
children/adolescents
Systemic
immunotherapy should
not be used in
combination with UV
Ministry of
Health Malaysia
Management of
Atopic
Emollients based on
patient preference No specific
recommendations
Bleach baths
recommended,
avoid long term use
Use with emollients,
FTU for amount, use
in flares and
proactively
Age 2 and
above, use in
flares and
proactively
Wet wrap
therapy for 14
days for non-
infected mod-
severe AD
Narrow band
UVB for
maintenance
therapy in
chronic
Oral prednisone: short
course
Cyclosporine first line,
azathioprine (check
TPMT), methotrexate,
(continued)
Volume 17, No. 12, Month 2024 13

Author, Title,
Year Emollients Bathing and
cleansing TCS
Topical
calcineurin
inhibitors
Wet wraps Phototherapy Immunosuppressants
Eczema
17
2018 disease
UVA1 as an
adjunct for
flares
mycophenolate mofetil
recommended for
severe AD
Turkish Society
of Dermatology
Turkish
Guideline for
Atopic
Dermatitis
2018
19
2018
Moisturisers directly
after bathing on
damp skin, 1–3 times
daily
Do not apply topical
medications
concurrently with
emollient
No specific
recommendations
Bleach baths
recommended twice
weekly
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Base amount on
age, site, size of
lesions
Use after topical
steroids in acute
flares and
proactively or for
sensitive areas
Use in treatment
resistant AD Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares in age
12þyears
Oral prednisone: short
course
First line - cyclosporine,
second line -
azathioprine (check
TPMT), third line -
methotrexate,
mycophenolate mofetil
recommended for
severe unresponsive AD,
IFN gamma
recommended as last
line
Monitoring
recommended for all
European Task
Force on Atopic
Dermatitis/
European
Academy of
Dermatology
and
Venereology
Position paper
of the diagnosis
and treatment
of atopic
dermatitis in
adults and
children
45
2018
Moisturisers directly
after bathing on
damp skin, at least
30 g/day. Base type
on patient
preference, however
glycerol better
tolerated than urea
in <5 years
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,2–
7 times/week. Can
use emollient bath
additives based on
patient choice
Apply topical
therapies 15 min
after bathing
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance. Avoid
super potent
steroids in children.
15 g/month in
infants, 30 g/month
in children, 60–90 g
in adolescents
Use after topical
steroids in acute
flares and
proactively. First
line for sensitive
areas.
Pimecrolimus in
mild AD,
tacrolimus in
moderate-
severe. Can use
off label in under
2 years
Wet wrap
therapy for 14
days for flares or
acute oozing/
erosive lesions
Not enough
evidence for
use in
prepubertal
age group,
otherwise
narrow band
UVB for
chronic, UVA1
for acute
flares
Systemic therapy in
under <2 years requires
specialist input
Oral prednisone: short
course or bridging
therapy
First line - cyclosporine,
second line -
azathioprine (check
TPMT, methotrexate,
third line -
mycophenolate mofetil
Brazilian Society
of Dermatology
Consensus on
the therapeutic
management of
atopic
dermatitis -
Brazilian Society
of
Dermatology
40
2019
Moisturisers directly
after bathing on
damp skin, 2 times
daily. Choice based
on patient
preference
Cleansing with
physiological pH
soap free cleansers,
up to 5 min
Bathing for up to
5 min
Bleach baths
recommended
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance.
15 g/month in
infants, 30 g/month
in children, 60–90 g
in adolescents
Second line
agent Wet wraps used
if hospitalised Narrow band
UVB for
chronic, UVA1
for acute
flares. Avoid
in eczema
herpeticum
Systemic therapy in
under <2 years requires
specialist input
Oral prednisone: short
course
Cyclosporine and
methotrexate most
widely used, few
dermatologists have
experience with
mycophenolate mofetil
or azathioprine
14 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

Canadian
Dermatology
Association
Approach to the
Assessment and
Management of
Pediatric
Patients With
Atopic
Dermatitis: A
Consensus
Document.
Section
3
42
þSection
4,
43
2019
Moisturisers daily
immediately after
bathing. Choice
based on patient
preference
Not enough
evidence for bleach
baths
Olive oil should be
avoided,
exacerbates xerosis
Bathing once daily
with lukewarm water
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Lack of evidence for
bleach baths
Bath additives not
recommended
Use topical
therapies prior to
moisturiser
Recommend FTU for
TCS
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2y. 0.1%
tacrolimus for
mod-severe in
>16 years
Proactive use
recommended
Short term use,
no standard
protocols for
duration,
frequency,
potency
Narrowband
UVB in mod-
severe AD
UVA1 not
discussed
Oral prednisone: short
course
First line - cyclosporine,
second line -
azathioprine (check
TPMT, methotrexate,
third line -
mycophenolate mofetil
Indian
Dermatology
Expert Board
Members
Guidelines on
Management of
Atopic
Dermatitis in
India:
An Evidence
–based Review
and an Expert
Consensus
44
2019
Moisturisers
recommended 2 or
more times daily,
choice based on
patient preference.
No clear evidence
on frequency,
technique, bath
additives
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30
deg, 5–10 min once
daily
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance.
Recommend using
FTU
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2years. 0.1%
tacrolimus for
mod-severe in
>16 years
Pimecrolimus
preferred in <2
years
Use in >6 months
old, for severe/
resistant AD
Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate (over 8
years old)
Mycophenolate mofetil
only recommended for
adults
SIDEMAST,
ADOI, SIDAPA
—Adapted from
consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis)
41
2019
Moisturisers
recommended
frequently
Bath oils and soap
substitutes
recommended
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for up
to 20 weeks
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2 years. 0.1%
tacrolimus for
mod-severe in
>16 years
Recommend sun
protection
Not discussed Narrowband
UVB in mod-
severe AD for
>10 years
UVA1 in acute
flares for >11
years
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate,
mycophenolate mofetil
can be used off label for
children
Taiwanese
dermatological
association
Taiwanese
Dermatological
Association
consensus for
the
management of
atopic
dermatitis: A
2020 update
46
2020
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing for 5–10 min
daily
Lack of evidence for
bath additives
Bleach baths or
hypochlorous acid
for maintenance in
mod-severe
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Use after topical
steroids in acute
flares and
proactively or for
sensitive areas
Not common
practice, low
quality evidence
Narrowband
UVB best
option for
children
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate,
mycophenolate mofetil
can be used off label for
children
(continued)
Volume 17, No. 12, Month 2024 15

Author, Title,
Year Emollients Bathing and
cleansing TCS
Topical
calcineurin
inhibitors
Wet wraps Phototherapy Immunosuppressants
Chinese Society
of Dermatology
Immunology
Guidelines for
the diagnosis
and treatment
of atopic
dermatitis in
China
47
2020
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,5–
10 min once daily
Bleach baths for
high risk of infection,
once every few days
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Use second line
in acute flares
and proactively
or for sensitive
areas
Recommended
for relapse Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares for >12
years
Oral prednisone: short
course or bridging
First line - cyclosporine,
second line –
azathioprine,
methotrexate
Japanese
Dermatological
Association
English Version
of Clinical
practice
guidelines for
the
Management of
Atopic
Dermatitis
2021
48
2021
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Bleach baths not
recommended
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for 2þ
weeks
Second line, not
to use under
occlusion,
tacrolimus can
be prophylactic
Only age 2þ
years
Use for severe
flares Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares for >12
years
Oral prednisone: short
course
Cyclosporin not
approved for children in
Japan
Asian Academy
of Dermatology
and
Venereology
Expert Panel on
Atopic
Dermatitis,
A clinician’s
reference guide
for the
management of
atopic
dermatitis in
Asians
37
2018
Moisturisers directly
after bathing on
damp skin, 2–3 times
daily
Support the use of
traditional
emollients like
coconut oil, olive oil
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Indicated in flares,
FTU recommended.
Start with mild
potency twice/day
after bathing
Indicated when
recalcitrant to
steroids,
prolonged
uninterrupted
steroid use,
steroid atrophy
or sensitive areas
including face,
anogenital, skin
folds, paediatric,
Use twice/day
after bathing
Recommended,
can use ‘double
pyjama method’
Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares
PUVA for
lichenification,
active and
stable disease
Recommended when
refractory to
conventional therapy,
severe disease with large
body surface area,
generalised exfoliative
dermatitis
Requires dermatologist
referral. All require
monitoring bloods
Oral prednisone:
minimum duration and
dose for acute flares or
bridging therapy, 0.5–
1mg/m2/day
Cyclosporine first line.
Methotrexate
recommended for
children. Azathioprine in
older children and
teenagers, second line,
recommend checking
TMPT. Mycophenolate
mofetil third line
16 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

EDF, EADV,
EAACI, ETFAD,
EFA, ESDaP,
ESPD,
GA2LEN, and
UEMS
Consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis) in
adults and
children: part
I
39
þII
38
2018
Moisturisers directly
after bathing on
damp skin, 2–3 times
daily
Do not recommend
pure oils like
coconut oil
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,5–
10 min. Can add
bleach or bath oils
(in last 2 min)
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for 20
weeks
Avoid super potent
steroids in children
Use after topical
steroids in acute
flares and
proactively. First
line for sensitive
areas.
Pimecrolimus in
mild AD,
tacrolimus in
mod-severe. Can
use off label in
under 2 years
Wet wrap
therapy for 14
days for severe/
refractory cases
Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares
Oral prednisone: 1 week
short term, acute flares
0.2–0.5mg/m2/day
Cyclosporine first line,
azathioprine (check
TPMT), methotrexate,
mycophenolate mofetil
can be used off label for
children/adolescents
Systemic
immunotherapy should
not be used in
combination with UV
Ministry of
Health Malaysia
Management of
Atopic
Eczema
17
2018
Emollients based on
patient preference No specific
recommendations
Bleach baths
recommended,
avoid long term use
Use with emollients,
FTU for amount, use
in flares and
proactively
Age 2 and
above, use in
flares and
proactively
Wet wrap
therapy for 14
days for non-
infected mod-
severe AD
Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares
Oral prednisone: short
course
Cyclosporine first line,
azathioprine (check
TPMT), methotrexate,
mycophenolate mofetil
recommended for
severe AD
Turkish Society
of Dermatology
Turkish
Guideline for
Atopic
Dermatitis
2018
19
2018
Moisturisers directly
after bathing on
damp skin, 1–3 times
daily
Do not apply topical
medications
concurrently with
emollient
No specific
recommendations
Bleach baths
recommended twice
weekly
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Base amount on
age, site, size of
lesions
Use after topical
steroids in acute
flares and
proactively or for
sensitive areas
Use in treatment
resistant AD Narrow band
UVB for
maintenance
therapy in
chronic
disease
UVA1 as an
adjunct for
flares in age
12þyears
Oral prednisone: short
course
First line - cyclosporine,
second line -
azathioprine (check
TPMT), third line -
methotrexate,
mycophenolate mofetil
recommended for
severe unresponsive AD,
IFN gamma
recommended as last
line
Monitoring
recommended for all
European Task
Force on Atopic
Dermatitis/
European
Academy of
Dermatology
and
Venereology
Moisturisers directly
after bathing on
damp skin, at least
30 g/day. Base type
on patient
preference, however
glycerol better
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,2–
7 times/week. Can
use emollient bath
Apply topical
therapies 15 min
after bathing
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance. Avoid
Use after topical
steroids in acute
flares and
proactively. First
line for sensitive
areas.
Pimecrolimus in
mild AD,
Wet wrap
therapy for 14
days for flares or
acute oozing/
erosive lesions
Not enough
evidence for
use in
prepubertal
age group,
otherwise
narrow band
UVB for
Systemic therapy in
under <2 years requires
specialist input
Oral prednisone: short
course or bridging
therapy
First line - cyclosporine,
second line -
(continued)
Volume 17, No. 12, Month 2024 17

Author, Title,
Year Emollients Bathing and
cleansing TCS
Topical
calcineurin
inhibitors
Wet wraps Phototherapy Immunosuppressants
Position paper
of the diagnosis
and treatment
of atopic
dermatitis in
adults and
children
45
2018
tolerated than urea
in <5 years additives based on
patient choice super potent
steroids in children.
15 g/month in
infants, 30 g/month
in children, 60–90 g
in adolescents
tacrolimus in
moderate-
severe. Can use
off label in under
2 years
chronic, UVA1
for acute
flares
azathioprine (check
TPMT, methotrexate,
third line -
mycophenolate mofetil
Brazilian Society
of Dermatology
Consensus on
the therapeutic
management of
atopic
dermatitis -
Brazilian Society
of
Dermatology
40
2019
Moisturisers directly
after bathing on
damp skin, 2 times
daily. Choice based
on patient
preference
Cleansing with
physiological pH
soap free cleansers,
up to 5 min
Bathing for up to
5 min
Bleach baths
recommended
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance.
15 g/month in
infants, 30 g/month
in children, 60–90 g
in adolescents
Second line
agent Wet wraps used
if hospitalised Narrow band
UVB for
chronic, UVA1
for acute
flares. Avoid
in eczema
herpeticum
Systemic therapy in
under <2 years requires
specialist input
Oral prednisone: short
course
Cyclosporine and
methotrexate most
widely used, few
dermatologists have
experience with
mycophenolate mofetil
or azathioprine
Canadian
Dermatology
Association
Approach to the
Assessment and
Management of
Pediatric
Patients With
Atopic
Dermatitis: A
Consensus
Document.
Section
3
42
þSection
4,
43
2019
Moisturisers daily
immediately after
bathing. Choice
based on patient
preference
Not enough
evidence for bleach
baths
Olive oil should be
avoided,
exacerbates xerosis
Bathing once daily
with lukewarm water
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Lack of evidence for
bleach baths
Bath additives not
recommended
Use topical
therapies prior to
moisturiser
Recommend FTU for
TCS
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2 years. 0.1%
tacrolimus for
mod-severe in
>16 years
Proactive use
recommended
Short term use,
no standard
protocols for
duration,
frequency,
potency
Narrowband
UVB in mod-
severe AD
UVA1 not
discussed
Oral prednisone: short
course
First line - cyclosporine,
second line -
azathioprine (check
TPMT, methotrexate,
third line -
mycophenolate mofetil
Indian
Dermatology
Expert Board
Members
Guidelines on
Management of
Atopic
Dermatitis in
India:
An Evidence
–based Review
and an Expert
Consensus
44
2019
Moisturisers
recommended 2 or
more times daily,
choice based on
patient preference.
No clear evidence
on frequency,
technique, bath
additives
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30
deg, 5–10 min once
daily
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance.
Recommend using
FTU
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2 years. 0.1%
tacrolimus for
mod-severe in
>16 years
Pimecrolimus
preferred in <2y
Use in >6 months
old, for severe/
resistant AD
Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate (over 8
years old)
Mycophenolate mofetil
only recommended for
adults
18 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

SIDEMAST,
ADOI, SIDAPA
—Adapted from
consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis)
41
2019
Moisturisers
recommended
frequently
Bath oils and soap
substitutes
recommended
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for up
to 20 weeks
Use in flares
0.03% tacrolimus
and 1%
pimecrolimus for
>2 years. 0.1%
tacrolimus for
mod-severe in
>16 years
Recommend sun
protection
Not discussed Narrowband
UVB in mod-
severe AD for
>10 years
UVA1 in acute
flares for >11
years
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate,
mycophenolate mofetil
can be used off label for
children
Taiwanese
dermatological
association
Taiwanese
Dermatological
Association
consensus for
the
management of
atopic
dermatitis: A
2020 update
46
2020
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing for 5–10 min
daily
Lack of evidence for
bath additives
Bleach baths or
hypochlorous acid
for maintenance in
mod-severe
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Use after topical
steroids in acute
flares and
proactively or for
sensitive areas
Not common
practice, low
quality evidence
Narrowband
UVB best
option for
children
Oral prednisone: short
course
First line - cyclosporine,
second line –
azathioprine,
methotrexate,
mycophenolate mofetil
can be used off label for
children
Chinese Society
of Dermatology
Immunology
Guidelines for
the diagnosis
and treatment
of atopic
dermatitis in
China
47
2020
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Bathing at 27–30,5–
10 min once daily
Bleach baths for
high risk of infection,
once every few days
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance
Use second line
in acute flares
and proactively
or for sensitive
areas
Recommended
for relapse Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares for >12
years
Oral prednisone: short
course or bridging
First line - cyclosporine,
second line –
azathioprine,
methotrexate
Japanese
Dermatological
Association
English Version
of Clinical
practice
guidelines for
the
Management of
Atopic
Dermatitis
2021
48
2021
Moisturisers directly
after bathing on
damp skin, 2 times
daily
Bleach baths not
recommended
Limited use of
hypoallergenic,
fragrance free,
physiological pH
soap free cleansers
Reactive use in
flares, proactive use
2x weekly can be
used as
maintenance for 2þ
weeks
Second line, not
to use under
occlusion,
tacrolimus can
be prophylactic
Only age 2þ
years
Use for severe
flares Narrowband
UVB in mod-
severe AD
UVA1 in acute
flares for >12
years
Oral prednisone: short
course
Cyclosporin not
approved for children in
Japan
Table 2. (Continued) Mainstay management recommendations from guidelines 2018–2023. Abbreviations: AD –Atopic dermatitis; EDF –European Dermatology Forum; EADV - European Academy
of Dermatology and Venereology; EAACI –European Academy of Allergy and Clinical Immunology; ETFAD –European Task Force on Atopic Dermatitis; EFA - European Federation of Allergy and Airways
Disease; ESDaP –European Society for Dermatology and Psychiatry; ESPD –European Society of Pediatric Dermatology; GA2LEN - Global Allergy and Asthma European Network; UEMS - European Union of
Medical Specialists; SIDEMAST - Italian Society of Medical, Surgical and Aesthetic Dermatology and Venereology; ADOI - Italian Society of Dermatologists and Venereologists Hospital-based and Public Health;
SIDAPA - Italian Society of Allergological Occupational and Environmental Dermatology; FTU –finger tip unit; PUVA –Psoralens ultraviolet A; TMPT –Thiopurine methyl transferase; UV - ultraviolet; UVA –
ultraviolet A; UBV –ultraviolet B; TCS –topical corticosteroids; IFN –interferon
Volume 17, No. 12, Month 2024 19

Author, Title,
Year Biologics Education Dietary and
allergy testing
Complementary
therapy and
Chinese Herbal
Medicine
Pruritis
control
Infection
control Other
Asian Academy
of Dermatology
and
Venereology
Expert Panel on
Atopic
Dermatitis,
A clinician’s
reference guide
for the
management of
atopic
dermatitis in
Asians
37
2018
Dupilumab for
adults only Eczema action plan,
nurse led education
programs,
instructional videos
Elimination diets not
recommended unless
proven allergy by food
challenge
Not enough evidence for
nutrient supplements e.g.
probiotics, prebiotics,
vitamin D tablets
Limited
evidence, not
recommended
Keep nails short,
wear light
clothing, avoid
synthetic fabrics
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
Topical
antibiotics - focal
infections
Avoid clinically
relevant
environmental
triggers however
exposure to pets is
recommended
New therapies
mentioned however
need further
research: Naltrexone,
antioxidant
moisturisers, topical
PDE4 inhibitors
EDF, EADV,
EAACI, ETFAD,
EFA, ESDaP,
ESPD,
GA2LEN, and
UEMS
Consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis) in
adults and
children: part
I
39
þII
38
2018
Dupilumab for
moderate to
severe when
topical or
systemic
therapies not
sufficient
Do not
recommend
rituximab,
omalizumab,
ustekinumab
Mepolizumab
can be trialled in
severe cases
Nurse led education
programs,
multidisciplinary
school programs
Elimination diets not
recommended unless
proven allergy by food
challenge
Early introduction of solids
Probiotics, unsaturated
fatty acids not
recommended
Allergen specific
immunotherapy for severe
AD with allergies to dust
mite, birch and grass
pollen with history of
clinical exacerbation or
patch test
Thermal spring
water may be
considered for
mild-moderate
AD
Sedating
antihistamines
can be used for
sleep in short
term
Do not
recommend
routine
antihistamines,
topical
cannabinoid
receptor
agonists, mu
receptor
antagonists,
anaesthetics
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics e.g.
diluted sodium
hypochlorite for
bacterial
infection, chronic
treatment
resistant AD
Avoid clinically
relevant
environmental
triggers, patch test
when necessary.
Avoid pets. Avoid hot
humid climates
Vaccinations
recommended as per
national plan
Sun protection
Psychosomatic
counselling,
behavioural therapy
techniques,
relaxation techniques
Hospitalisation for
severe cases
Not recommending
tofacitinib, mast cell
stabilisers,
leukotriene
antagonists, IVIG
PDE4 inhibitors in
select cases
Ministry of
Health Malaysia
Management of
Atopic
Eczema
17
2018
Dupilumab:
Adults
No omalizumab,
infliximab
Workshops, written
action plans Elimination diets or
supplements not
recommended
Consider food allergy
diagnoses. Allergen
specific immunotherapy
not recommended
Not
recommended
over
conventional
therapy
Sedating
antihistamines
can be used for
sleep in short
term
Systemic
antibiotics for
staph aureus
Avoid clinically
relevant
environmental
triggers
Routine vaccinations
PDE4 and JAK
inhibitors under study
No IVIG, leukotriene
antagonists,
interferon gamma
20 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

Turkish Society
of Dermatology
Turkish
Guideline for
Atopic
Dermatitis
2018
19
2018
Dupilumab –
adults
Ustekinumab and
Omalizumab –
lack of evidence
Support programs,
linking with
community support
groups
Elimination diets or
probiotics not
recommended
Fatty acid
supplementation could be
considered, replace
vitamin D only if deficient
Do not
recommend
Chinese herbal
medicine
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Lack evidence for
antiseptic baths
Topical
antiseptics for
bacterial
infection, not
long term
Avoid clinically
relevant
environmental
triggers
Topical coal tar
recommended in
children
Further research
required for PDE4
inhibitors,
polidocanol, tannins
Do not recommend
zinc, topical NSAIDs
Consider psychiatric
input
European Task
Force on Atopic
Dermatitis/
European
Academy of
Dermatology
and
Venereology
Position paper
of the diagnosis
and treatment
of atopic
dermatitis in
adults and
children
45
2018
Dupilumab –
moderate to
severe, age 12þ
years
Therapeutic parent
and child education
–interdisciplinary
programs e.g.,
eczema school,
written action plans
Multimodal
education programs
e.g., relaxation and
habit-reversal
techniques
Elimination diets or
supplements not
recommended
Allergy workup including
serum IgE, skin prick tests,
patch testing depending
on individual history for
moderate-severe eczema
Mild eczema –test for
allergies based on clinical
suspicion
Patch testing for refractory
with atypical skin lesions or
triggers
Allergen specific
immunotherapy for select
patients with dust mite
birch or grass pollen
sensitisation þsevere AD
and clinical exacerbation
or patch test positive
Not
recommended Antihistamines:
H1RA could be
used for
treatment as 3rd
line
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
Can consider
high quality silver
garments in
patients with
high risk of
infection
Further research
required for JAK
inhibitors, topical tar,
PDE4 inhibitors
Alitretinoin in hand
eczema
Aim to minimise
treatment cost, follow
up frequently, send
reminders
Special attention to
adolescents including
counselling about
body image,
relationships,
psychotherapy,
avoiding careers with
high risk of
complications e.g.,
chefs, bakers,
painters
Brazilian Society
of Dermatology
Consensus on
the therapeutic
management of
atopic
Dupilumab –
requires ongoing
studies
Recommended, no
details Elimination diets not
recommended, however
consider investigating
allergies in severe,
treatment-resistant AD and
history of flares following
Not mentioned Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
Further research
required for PDE4
inhibitors
(continued)
Volume 17, No. 12, Month 2024 21

Author, Title,
Year Biologics Education Dietary and
allergy testing
Complementary
therapy and
Chinese Herbal
Medicine
Pruritis
control
Infection
control Other
dermatitis -
Brazilian Society
of
Dermatology
40
2019
ingestion of specific foods
Patch testing for refractory
with atypical skin lesions
Routine skin prick tests or
RAST tests not
recommended
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
Canadian
Dermatology
Association
Approach to the
Assessment and
Management of
Pediatric
Patients With
Atopic
Dermatitis: A
Consensus
Document.
Section
3
42
þSection
4,
43
2019
Dupilumab –
mod-severe in
12þyears
Eczema action plan,
pictograms for
counselling and
education
Elimination diets or
supplementation not
recommended
Routine allergy testing not
recommended
Not
recommended Sedating
antihistamines
not
recommended in
paediatric
patients
Not discussed Avoid clinically
relevant
environmental
triggers
Further research into
JAK inhibitors, other
biologics
PDE4 inhibitors first
line –2% crisaborole
in mild-moderate AD
2years
Indian
Dermatology
Expert Board
Members
Guidelines on
Management of
Atopic
Dermatitis in
India:
An Evidence
–based Review
and an Expert
Consensus
44
2019
Dupilumab -
adults only
Aprelimast 3rd
line
Recommend
education at each
consult
Elimination diets or
supplementation not
recommended unless
vitamin D deficiency
Not discussed Antihistamines
recommended in
patients with
concurrent
allergic rhinitis
and bronchial
asthma
Sedating
antihistamines
can be used for
sleep in short
term for >2years
Short course
topical/oral
antibiotics for
overt infection.
Not for long term
use.
Avoid clinically
relevant
environmental
triggers, tight
clothing,
occupational triggers
PDE4 inhibitors can
be used off label
Psychosomatic and
psychological
interventions
Alitretinoin for hand
eczema
SIDEMAST,
ADOI, SIDAPA
—Adapted from
consensus-
based
European
guidelines for
Dupilumab –
adults only
Neolizumab for
second line -
adults
Internet based
education programs Elimination diets or
supplementation not
recommended
Allergen specific
immunotherapy for select
patients with dust mite
birch or grass pollen
Thermal spring
water and
unsaturated fatty
acids may be
considered
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
Avoid clinically
relevant
environmental
triggers, including
smoking,
occupational triggers
Routine vaccinations
22 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

treatment of
atopic eczema
(atopic
dermatitis)
41
2019
sensitisation þsevere AD
and clinical exacerbation
or patch test positive
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
recommended aside
from intracutaneous
smallpox vaccination
with attenuated live
vaccine –may lead to
life- threatening
eczema vaccinatum
Further research
required for
aprelimast and JAK
inhibitors
Leukotrienes, IVIG not
recommended
Psychological
support –behavioural
therapy, relaxation
techniques,
counselling
Taiwanese
dermatological
association
Taiwanese
Dermatological
Association
consensus for
the
management of
atopic
dermatitis: A
2020 update
46
2020
Dupilumab –
>12years Recommended, no
preference for
specific tool
Not discussed Not
recommended Recommended
in initial acute
control in those
with urticaria,
dermographism,
allergic rhinitis
and bronchial
asthma
Sedating
antihistamines
can be used for
sleep in short
term for >2years
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Antiseptics not
recommended
Patients and
caregivers should be
informed that in
patients with more
pigmented skin, AD
may temporarily
cause the skin to
lighten or darken
Melatonin for sleep
disturbance
Assess mental health
comorbidities
through
psychologists and
multidisciplinary
teams
Chinese Society
of Dermatology
Immunology
Guidelines for
the diagnosis
and treatment
of atopic
dermatitis in
China
47
2020
Dupilumab –
adults
JAK inhibitors -
adults
Recommended, no
specific
recommendations
For mod-severe AD in <3y,
routinely test for cow’s
milk, eggs, wheat, soy,
peanut allergies
In >5y, test based on
history findings. Consider
fish allergies in childhood,
pollen/apples/celery/
carrot in older kids
Recommend diagnostic
elimination diets for 4–6
weeks
Avoid contact allergens
like nickel, neomycin,
fragrance, formaldehyde,
preservatives, lanolin,
rubber
Recommend dust mite
immunotherapy with
severe AD and allergy to
dust mite
Chinese herbal
medicine based
on clinical
symptoms and
signs
Non-sedating
second
generation
antihistamines
adjuvant for
pruritis with
concurrent
urticaria, allergic
rhinitis
Sedating
antihistamines
can be used for
sleep in short
term
Last line:
mirtazapine,
pregabalin,
paroxetine,
naltrexone
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Antiseptics not
recommended
Avoid clinically
relevant
environmental
triggers
PDE4 inhibitors
recommended in
>2years
Sodium thiosulfate,
glycyrrhizin injections
- need more evidence
Hospitalisation for
severe AD
(continued)
Volume 17, No. 12, Month 2024 23

Author, Title,
Year Biologics Education Dietary and
allergy testing
Complementary
therapy and
Chinese Herbal
Medicine
Pruritis
control
Infection
control Other
Japanese
Dermatological
Association
English Version
of Clinical
practice
guidelines for
the
Management of
Atopic
Dermatitis
2021
48
2021
Dupilumab –
mod-severe AD
Baricitinib –orally
in mod-severe
AD
Delgocitinib
ointment is
recommended
for patients with
AD aged 2
years
Recommended at
each consult,
community support
groups, nurse led
programs
Elimination diets and
supplementation not
recommended
Chinese herbal
medicines may
be used in
combination with
traditional
therapy in
refractory cases
Sedating
antihistamines
can be used for
sleep in short
term
Topical
antibiotics for
localised
infections in short
term, systemic for
up to 1 week
Avoid clinically
relevant
environmental
triggers
Including dust mites
Asian Academy
of Dermatology
and
Venereology
Expert Panel on
Atopic
Dermatitis,
A clinician’s
reference guide
for the
management of
atopic
dermatitis in
Asians
37
2018
Dupilumab
adults only Eczema action plan,
nurse led education
programs,
instructional videos
Elimination diets not
recommended unless
proven allergy by food
challenge
Not enough evidence for
nutrient supplements e.g.
probiotics, prebiotics,
vitamin D tablets
Limited
evidence, not
recommended
Keep nails short,
wear light
clothing, avoid
synthetic fabrics
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
Topical
antibiotics - focal
infections
Avoid clinically
relevant
environmental
triggers however
exposure to pets is
recommended
New therapies
mentioned however
need further
research: Naltrexone,
antioxidant
moisturisers, topical
PDE4 inhibitors
EDF, EADV,
EAACI, ETFAD,
EFA, ESDaP,
ESPD,
GA2LEN, and
UEMS
Consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis) in
adults and
children: part
I
39
þII
38
2018
Dupilumab for
moderate to
severe when
topical or
systemic
therapies not
sufficient
Do not
recommend
rituximab,
omalizumab,
ustekinumab
Mepolizumab
can be trialled in
severe cases
Nurse led education
programs,
multidisciplinary
school programs
Elimination diets not
recommended unless
proven allergy by food
challenge
Early introduction of solids
Probiotics, unsaturated
fatty acids not
recommended
Allergen specific
immunotherapy for severe
AD with allergies to dust
mite, birch and grass
pollen with history of
clinical exacerbation or
patch test
Thermal spring
water may be
considered for
mild-moderate
AD
Sedating
antihistamines
can be used for
sleep in short
term
Do not
recommend
routine
antihistamines,
topical
cannabinoid
receptor
agonists, mu
receptor
antagonists,
anaesthetics
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics e.g.
diluted sodium
hypochlorite for
bacterial
Avoid clinically
relevant
environmental
triggers, patch test
when necessary.
Avoid pets. Avoid hot
humid climates
Vaccinations
recommended as per
national plan
Sun protection
Psychosomatic
counselling,
behavioural therapy
techniques,
relaxation techniques
Hospitalisation for
severe cases
Not recommending
24 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

infection, chronic
treatment
resistant AD
tofacitinib, mast cell
stabilisers,
leukotriene
antagonists, IVIG
PDE4 inhibitors in
select cases
Ministry of
Health Malaysia
Management of
Atopic
Eczema
17
2018
Dupilumab:
Adults
No omalizumab,
infliximab
Workshops, written
action plans Elimination diets or
supplements not
recommended
Consider food allergy
diagnoses. Allergen
specific immunotherapy
not recommended
Not
recommended
over
conventional
therapy
Sedating
antihistamines
can be used for
sleep in short
term
Systemic
antibiotics for
staph aureus
Avoid clinically
relevant
environmental
triggers
Routine vaccinations
PDE4 and JAK
inhibitors under study
No IVIG, leukotriene
antagonists,
interferon gamma
Turkish Society
of Dermatology
Turkish
Guideline for
Atopic
Dermatitis
2018
19
2018
Dupilumab –
adults
Ustekinumab and
Omalizumab –
lack of evidence
Support programs,
linking with
community support
groups
Elimination diets or
probiotics not
recommended
Fatty acid
supplementation could be
considered, replace
vitamin D only if deficient
Do not
recommend
Chinese herbal
medicine
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Lack evidence for
antiseptic baths
Topical
antiseptics for
bacterial
infection, not
long term
Avoid clinically
relevant
environmental
triggers
Topical coal tar
recommended in
children
Further research
required for PDE4
inhibitors,
polidocanol, tannins
Do not recommend
zinc, topical NSAIDs
Consider psychiatric
input
European Task
Force on Atopic
Dermatitis/
European
Academy of
Dermatology
and
Venereology
Position paper
of the diagnosis
and treatment
of atopic
dermatitis in
Dupilumab –
moderate to
severe, age 12þ
Therapeutic parent
and child education
–interdisciplinary
programs e.g.
eczema school,
written action plans
Multimodal
education programs
e.g. relaxation and
habit-reversal
techniques
Elimination diets or
supplements not
recommended
Allergy workup including
serum IgE, skin prick tests,
patch testing depending
on individual history for
moderate-severe eczema
Mild eczema –test for
allergies based on clinical
suspicion
Patch testing for refractory
with atypical skin lesions or
Not
recommended Antihistamines:
H1RA could be
used for
treatment as 3rd
line
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
Further research
required for JAK
inhibitors, topical tar,
PDE4 inhibitors
Alitretinoin in hand
eczema
Aim to minimise
treatment cost, follow
up frequently, send
reminders
Special attention to
adolescents including
counselling about
(continued)
Volume 17, No. 12, Month 2024 25

Author, Title,
Year Biologics Education Dietary and
allergy testing
Complementary
therapy and
Chinese Herbal
Medicine
Pruritis
control
Infection
control Other
adults and
children
45
2018
triggers
Allergen specific
immunotherapy for select
patients with dust mite
birch or grass pollen
sensitisation þsevere AD
and clinical exacerbation
or patch test positive
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
Can consider
high quality silver
garments in
patients with
high risk of
infection
body image,
relationships,
psychotherapy,
avoiding careers with
high risk of
complications e.g.
chefs, bakers,
painters
Brazilian Society
of Dermatology
Consensus on
the therapeutic
management of
atopic
dermatitis -
Brazilian Society
of
Dermatology
40
2019
Dupilumab –
requires ongoing
studies
Recommended, no
details Elimination diets not
recommended, however
consider investigating
allergies in severe,
treatment-resistant AD and
history of flares following
ingestion of specific foods
Patch testing for refractory
with atypical skin lesions
Routine skin prick tests or
RAST tests not
recommended
Not mentioned Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
Further research
required for PDE4
inhibitors
Canadian
Dermatology
Association
Approach to the
Assessment and
Management of
Pediatric
Patients With
Atopic
Dermatitis: A
Consensus
Document.
Section
3
42
þSection
4,
43
2019
Dupilumab –
mod-severe in
12þyears
Eczema action plan,
pictograms for
counselling and
education
Elimination diets or
supplementation not
recommended
Routine allergy testing not
recommended
Not
recommended Sedating
antihistamines
not
recommended in
paediatric
patients
Not discussed Avoid clinically
relevant
environmental
triggers
Further research into
JAK inhibitors, other
biologics
PDE4 inhibitors first
line –2% crisaborole
in mild-moderate AD
2y
26 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

Indian
Dermatology
Expert Board
Members
Guidelines on
Management of
Atopic
Dermatitis in
India:
An Evidence
–based Review
and an Expert
Consensus
44
2019
Dupilumab -
adults only
Aprelimast 3rd
line
Recommend
education at each
consult
Elimination diets or
supplementation not
recommended unless
vitamin D deficiency
Not discussed Antihistamines
recommended in
patients with
concurrent
allergic rhinitis
and bronchial
asthma
Sedating
antihistamines
can be used for
sleep in short
term for >2years
Short course
topical/oral
antibiotics for
overt infection.
Not for long term
use.
Avoid clinically
relevant
environmental
triggers, tight
clothing,
occupational triggers
PDE4 inhibitors can
be used off label
Psychosomatic and
psychological
interventions
Alitretinoin for hand
eczema
SIDEMAST,
ADOI, SIDAPA
—Adapted from
consensus-
based
European
guidelines for
treatment of
atopic eczema
(atopic
dermatitis)
41
2019
Dupilumab –
adults only
Neolizumab for
second line -
adults
Internet based
education programs Elimination diets or
supplementation not
recommended
Allergen specific
immunotherapy for select
patients with dust mite
birch or grass pollen
sensitisation þsevere AD
and clinical exacerbation
or patch test positive
Thermal spring
water and
unsaturated fatty
acids may be
considered
Sedating
antihistamines
can be used for
sleep in short
term
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Topical
antiseptics for
bacterial
infection, not
long term
Avoid clinically
relevant
environmental
triggers, including
smoking,
occupational triggers
Routine vaccinations
recommended aside
from intracutaneous
smallpox vaccination
with attenuated live
vaccine –may lead to
life- threatening
eczema vaccinatum
Further research
required for
aprelimast and JAK
inhibitors
Leukotrienes, IVIG not
recommended
Psychological
support –behavioural
therapy, relaxation
techniques,
counselling
Taiwanese
dermatological
association
Taiwanese
Dermatological
Association
consensus for
the
management of
atopic
dermatitis: A
Dupilumab –
>12years Recommended, no
preference for
specific tool
Not discussed Not
recommended Recommended
in initial acute
control in those
with urticaria,
dermographism,
allergic rhinitis
and bronchial
asthma
Sedating
antihistamines
can be used for
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
Patients and
caregivers should be
informed that in
patients with more
pigmented skin, AD
may temporarily
cause the skin to
lighten or darken
Melatonin for sleep
disturbance
Assess mental health
comorbidities
(continued)
Volume 17, No. 12, Month 2024 27

Author, Title,
Year Biologics Education Dietary and
allergy testing
Complementary
therapy and
Chinese Herbal
Medicine
Pruritis
control
Infection
control Other
2020 update
46
2020 sleep in short
term for >2years systemic
antifungals
Antiseptics not
recommended
through
psychologists and
multidisciplinary
teams
Chinese Society
of Dermatology
Immunology
Guidelines for
the diagnosis
and treatment
of atopic
dermatitis in
China
47
2020
Dupilumab –
adults
JAK inhibitors -
adults
Recommended, no
specific
recommendations
For mod-severe AD in <3y,
routinely test for cow’s
milk, eggs, wheat, soy,
peanut allergies
In >5y, test based on
history findings. Consider
fish allergies in childhood,
pollen/apples/celery/
carrot in older kids
Recommend diagnostic
elimination diets for 4–6
weeks
Avoid contact allergens
like nickel, neomycin,
fragrance, formaldehyde,
preservatives, lanolin,
rubber
Recommend dust mite
immunotherapy with
severe AD and allergy to
dust mite
Chinese herbal
medicine based
on clinical
symptoms and
signs
Non-sedating
second
generation
antihistamines
adjuvant for
pruritis with
concurrent
urticaria, allergic
rhinitis
Sedating
antihistamines
can be used for
sleep in short
term
Last line:
mirtazapine,
pregabalin,
paroxetine,
naltrexone
Staph aureus
infections -
systemic
antibiotics
Eczema
herpeticum-
systemic
antivirals
HþN AD with
Malassezia
colonisation:
topical or
systemic
antifungals
Antiseptics not
recommended
Avoid clinically
relevant
environmental
triggers
PDE4 inhibitors
recommended in
>2years
Sodium thiosulfate,
glycyrrhizin injections
- need more evidence
Hospitalisation for
severe AD
Japanese
Dermatological
Association
English Version
of Clinical
practice
guidelines for
the
Management of
Atopic
Dermatitis
2021
48
2021
Dupilumab –
mod-severe AD
Baricitinib –orally
in mod-severe
AD
Delgocitinib
ointment is
recommended
for patients with
AD aged 2
years
Recommended at
each consult,
community support
groups, nurse led
programs
Elimination diets and
supplementation not
recommended
Chinese herbal
medicines may
be used in
combination with
traditional
therapy in
refractory cases
Sedating
antihistamines
can be used for
sleep in short
term
Topical
antibiotics for
localised
infections in short
term, systemic for
up to 1 week
Avoid clinically
relevant
environmental
triggers
Including dust mites
Table 3. (Continued) Novel and complementary management recommendations from guidelines 2018–2023. Abbreviations: AD –Atopic dermatitis; EDF –European Dermatology Forum; EADV -
European Academy of Dermatology and Venereology; EAACI –European Academy of Allergy and Clinical Immunology; ETFAD –European Task Force on Atopic Dermatitis; EFA - European Federation of Allergy
and Airways Disease; ESDaP –European Society for Dermatology and Psychiatry; ESPD –European Society of Pediatric Dermatology; GA2LEN - Global Allergy and Asthma European Network; UEMS - European
Union of Medical Specialists; SIDEMAST - Italian Society of Medical, Surgical and Aesthetic Dermatology and Venereology; ADOI - Italian Society of Dermatologists and Venereologists Hospital-based and Public
Health; SIDAPA - Italian Society of Allergological Occupational and Environmental Dermatology
28 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

Guideline Name Domain 1:
Total Score
Domain 2:
Total Score
Domain 3:
Total Score
Domain 4:
Total Score
Domain 5:
Total Score
Domain 6:
Total Score
Overall
quality
Cut-off
met
1 Childhood Atopic Eczema
Consensus Document - Allergy
Society of South Africa
20
30.56% 11.11% 15.63% 55.56% 0.00% 0.00% 33.33% No
2 Diagnosis and treatment of atopic
dermatitis in children and adults:
European Academy of Allergology
and Clinical Immunology/American
Academy of Allergy, Asthma and
Immunology/PRACTALL Consensus
Report - European Academy of
Allergology and Clinical
Immunology/American Academy of
Allergy, Asthma and Immunology/
PRACTALL
21
44.44% 27.78% 18.75% 50.00% 8.33% 12.50% 41.67% No
3 Guidelines on the management of
atopic dermatitis in South Africa -
Dermatological, Paediatric (SAPA)
and Allergy (ALLSA) Societies of
South Africa
15
75.00% 47.22% 35.42% 77.78% 16.67% 4.17% 41.67% No
4 Eczema - atopic eczema - Scottish
Guideline, Primary Care
Dermatological Society
18
91.67% 69.44% 78.13% 86.11% 75.00% 58.33% 83.33% Yes
5 Atopic dermatitis: a practice
parameter update 2012 - American
Academy of Allergy, Asthma and
Immunology, American College of
Allergy, Asthma & Immunology
(ACAAI); and the Joint Council of
Allergy, Asthma and Immunology
24
63.89% 55.56% 48.96% 88.89% 22.92% 58.33% 67.67% Yes
6 Clinical guidelines on management
of atopic dermatitis in children -
Hong Kong College of
Paediatricians
22
77.78% 25.00% 17.71% 61.11% 2.08% 0.00% 33.33% No
7 Atopic eczema in children:
Management of atopic eczema in
children from birth up to the age of
12 years - NICE
16
100.00% 100.00% 97.92% 83.33% 93.75% 95.83% 100.00% Yes
8 Consensus guidelines for the
management of atopic dermatitis -
an Asia-Pacific perspective - Asia-
Pacific Consensus Group for Atopic
Dermatitis
23
77.78% 41.67% 14.58% 72.22% 16.67% 54.17% 41.67% No
(continued)
Volume 17, No. 12, Month 2024 29

Guideline Name Domain 1:
Total Score
Domain 2:
Total Score
Domain 3:
Total Score
Domain 4:
Total Score
Domain 5:
Total Score
Domain 6:
Total Score
Overall
quality
Cut-off
met
9 Clinical report on atopic dermatitis -
skin-directed management -
American Academy of Paediatrics
30
77.78% 41.67% 21.88% 55.56% 6.25% 91.67% 50% No
10 Guidelines of care for the
management of atopic dermatitis:
Section 1–4 - American Academy of
Dermatology
25,26,28,29
83.33% 38.89% 83.33% 94.44% 16.67% 91.67% 83.33% Yes
11 Atopic dermatitis guideline. Position
paper from the Latin American
Society of Allergy, Asthma and
Immunology
27
75.00% 63.89% 69.79% 80.56% 20.83% 12.50% 58.33% Yes
12 Atopic dermatitis: current treatment
guidelines. Statement of the experts
of the dermatological section –
Polish society of allergology, and
the allergology section, Polish
society of dermatology
33
30.56% 11.11% 14.58% 47.22% 0.00% 12.50% 25.00% No
13 Consensus guidelines for the
treatment of atopic dermatitis in
Korea Part I,II - Korean Atopic
Dermatitis Association
31,32
72.22% 27.78% 64.58% 77.78% 12.50% 16.67% 66.67% Yes
14 Consensus Conference on Clinical
Management of pediatric Atopic
Dermatitis - Italian Society of
Pediatric Allergology and
Immunology (SIAIP) and the Italian
Society of Pediatric Dermatology
(SIDerP)
34
69.44% 27.78% 25.00% 77.78% 8.33% 8.33% 41.67% No
15 S2k guideline on diagnosis and
treatment of atopic dermatitis—Short
version - German Society
Dermatology
36
91.67% 58.33% 65.63% 94.44% 16.67% 45.83% 83.33% Yes
16 Guidelines for the management of
atopic dermatitis in Singapore -
Dermatological Society of
Singapore
35
50.00% 19.44% 15.63% 61.11% 29.17% 0.00% 33.33% No
17 A clinician’s reference guide for the
management of atopic dermatitis in
Asians - Asian Academy of
Dermatology and Venereology
Expert Panel on Atopic Dermatitis
37
77.78% 41.67% 39.58% 77.78% 33.33% 50.00% 50.00% No
30 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

18 Consensus-based European
guidelines for treatment of atopic
eczema (atopic dermatitis) in adults
and children: part I, II - European
Dermatology Forum (EDF), EADV,
European Academy of Allergy and
Clinical Immunology (EAACI),
ETFAD, European Federation of
Allergy and Airways Diseases
Patients’Associations (EFA),
European Society for Dermatology
and Psychiatry (ESDaP), European
Society of Pediatric Dermatology
(ESPD), Global Allergy and Asthma
European Network (GA2LEN), and
European Union of Medical
Specialists (UEMS)
38,39
91.67% 88.89% 83.33% 88.89% 37.50% 62.50% 91.67% Yes
19 Management of Atopic Eczema -
Ministry of Health Malaysia
17
94.44% 72.22% 89.58% 91.67% 91.67% 87.50% 91.67% Yes
20 Turkish Guideline for Atopic
Dermatitis 2018 - Turkish Society of
Dermatology
19
25.00% 13.89% 16.67% 66.67% 8.33% 0.00% 25.00% No
21 Position paper of the diagnosis and
treatment of atopic dermatitis in
adults and children - European Task
Force on Atopic Dermatitis/
European Academy of Dermatology
and Venereology
45
52.78% 27.78% 32.29% 75.00% 16.67% 62.50% 58.33% No
22 Approach to the Assessment and
Management of Pediatric Patients
With Atopic Dermatitis: A
Consensus Document. Section
III þIV Canadian Dermatological
Association
42,43
75.00% 52.78% 58.33% 75.00% 39.58% 66.67% 75% Yes
23 Consensus on the therapeutic
management of atopic dermatitis -
Brazilian Society of Dermatology
40
52.78% 25.00% 29.17% 69.44% 27.08% 58.33% 41.67% No
24 Guidelines on Management of
Atopic Dermatitis in India: An
Evidence –based Review and an
Expert Consensus - Indian
Dermatology Expert Board
Members
44
88.89% 41.67% 45.83% 83.33% 18.75% 8.33% 58.33% No
25 Italian guidelines for therapy of
atopic dermatitis—Adapted from
consensus-based European
77.78% 47.22% 66.67% 61.11% 10.42% 16.67% 58.33% Yes
(continued)
Volume 17, No. 12, Month 2024 31

Guideline Name Domain 1:
Total Score
Domain 2:
Total Score
Domain 3:
Total Score
Domain 4:
Total Score
Domain 5:
Total Score
Domain 6:
Total Score
Overall
quality
Cut-off
met
guidelines for treatment of atopic
eczema (atopic dermatitis) –
SIDEMAST (Italian Society of
Medical, Surgical and Aesthetic
Dermatology and Venereology),
ADOI (Italian Society of
Dermatologists and Venereologists
Hospital-based and Public Health),
and SIDAPA (Italian Society of
Allergological Occupational and
Environmental Dermatology)
41
26 Taiwanese Dermatological
Association consensus for the
management of atopic dermatitis: A
2020 update.
46
77.78% 27.78% 40.63% 72.22% 4.17% 25.00% 50.00% No
27 Guidelines for the diagnosis and
treatment of atopic dermatitis in
China - Chinese Society of
Dermatology Immunology
47
52.78% 36.11% 14.58% 50.00% 8.33% 8.33% 33.33% No
28 Clinical practice guidelines for the
Management of Atopic Dermatitis
2021 - Japanese Dermatological
Association
48
88.89% 47.22% 61.46% 75.00% 33.33% 95.83% 66.67% Yes
Average domain score 70.24% 42.46% 45.20% 73.21% 24.11% 39.43% 56.58%
Table 4. (Continued) Domain scores for AGREE II appraisal
32 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

(applicability) had the lowest average score of
24%, with only 3/28 guidelines scoring over
50%.
16–18
The score given for overall quality
generally correlated with a satisfactory cut-off
score, indicating a high value placed on rigour of
development (Domain 3) by the reviewers. There
were 2 guidelines that had an overall quality of
over 50% that did not meet cut-off criteria as the
score for rigour of development was below
50%.
44,45
DISCUSSION
This review identified, compared, and quality
appraised 28 guidelines that included recom-
mendations for the management of paediatric AD.
While a similar review was conducted by Wang
et al,
50
this review differs as it considers guidelines
developed between 2005 and 2021 and provides
a more detailed comparison of management
recommendations with specific reference to skin
of colour.
Recommendations
There was little variation in management rec-
ommendations with regards to emollients, topical
steroids, topical calcineurin inhibitors, photo-
therapy, managing infections, and immunosup-
pressants. Other similar management strategies
included education and avoiding environmental
triggers. Although early onset eczema is a risk
factor for developing food allergies,
51
almost all
guidelines were in line with recommendations to
avoid elimination diets and allergy testing in
patients unless clinically implicated.
17,19,37–48
Some discrepancies were found regarding skin
care measures. Three guidelines had differing in-
formation surrounding traditional emollients
37–
39,42,43
Emollients containing food protein are
not usually recommended due to concerns
related to the risk of allergic sensitisation.
However, a review published in 2018 reported no
adverse events when using coconut oil as an
emollient for AD.
52
There were differing
recommendations as to whether emollients
should be applied before or after topical
therapies; however, a randomised controlled trial
(RCT) that directly compared the 2 methods
found no significant difference in severity and
this was also reflected in the 2023 update for the
NICE guideline.
16,53
Use of bleach baths had
varying degrees of evidence and was
recommended by 50% of the guidelines. In a
systematic review from 2022, use of bleach baths
was associated with a clinician-reported improve-
ment in severity by 22% for patients with
moderate-to-severe AD. There was low certainty
evidence that bleach baths reduce staphylococcus
aureus colonisation or patient-reported improve-
ment in severity.
54
With regards to bath additives
(recommended in 4/12 guidelines), a large RCT
of 483 children examined their effectiveness, and
found no significant change in severity compared
to no additives for 12 months.
55
Further research
would be beneficial to support these
recommendations in future guidelines.
Overall, the guidelines lacked information about
the age cut-offs for certain medications in AD
management. Topical calcineurin inhibitors are
only approved in children over 2 years of age,
however, as stated in 3/12 guidelines, 0.1% tacro-
limus is often used off-label in infants. There are a
lack of studies in children under 2 years; however,
1 large 3-year clinical study from Finland found it
was safe to use in moderate to severe AD.
56
In
2019, dupilumab was approved by the United
States Food and Drug Administration (FDA) for
use in children with moderate-severe AD 12
years and older. Multiple guidelines published af-
ter this time only recommended use in
adults.
40,41,44,47
It was then extended for use in
children 6 years and older in 2020, followed by 6
months in 2021. The most recent guideline from
Japan in 2021, is the only guideline to
recommend use in any age group.
48
Future
guidelines should be updated to reflect these
changes.
Multiple guidelines recommended newer ther-
apies such as topical PDE4 inhibitors. Crisaborole
is approved by the Food and Drug Administration,
Therapeutic Goods Administration, and European
Union in mild-moderate AD for ages 2 and older.
The 2021 NICE guideline did not recommend its
use due to insufficient evidence from clinical tri-
als.
57
Oral antihistamines for pruritis are another
point of contention. Although sedating
antihistamines are widely used to help with sleep
and pruritis, there remains low quality evidence
for their use as an add-on therapy.
58
Volume 17, No. 12, Month 2024 33

Skin of colour
Very few guidelines discussed eczema manage-
ment in skin ofcolour in detail. Most guidelines were
from Asia, 1 was from the United Kingdom and 1
from Latin America. As we live in a multicultural,
globalised world, it is important for all guidelines to
generatean understanding of AD management in all
skin types. Two guidelines mentioned phenotypical
differences in skin of colour. These include differ-
ences Asian, European, and African peoples’filag-
grin gene mutations, total epidermal water loss, and
the expression of T helper (TH) 2, Th22, Th17, and
Th1 pathways.
9
The different ways AD can present
were mentioned in 3 guidelines. Asian people are
more likely to have psoriatiform lesions, and Black
people may have distribution on the extensor
surfaces, perifollicular papules, and a lichen planus
appearance. Other known signs in skin of colour
include Dennie-Morgan lines, diffuse xerosis,
palmar hyperlinearity, prurigo nodularis and post-
inflammatory hypopigmentation.
7,9,59,60
The ability
to recognise these features should be enforced in
all guidelines.
Erythema often presents as violaceous in skin of
colour, therefore scoring systems like the Scoring
Atopic Dermatitis (SCORAD) index and the Eczema
Area and Severity Index (EASI) which use redness as a
marker of severity can be less accurate at identifying
severe cases.
61–63
The pattern of lichenification in
these scoring system also differs with skin of colour,
where chronic lesions can appear follicular in
darker skin rather than like deep furrows in
Caucasian skin.
64
In addition these scores are often
used to measure response to biological treatments,
which again limits their use in skin of colour. The
NICE guidelines did mention this, however did not
provide alternatives to severity assessments. Some
alternative scoring systems were mentioned in the
Chinese guidelines.
47
Future guidelines should
provide information on the different clinical
presentations and markers of severity for skin of
colour as described above. They should also
incorporate specific information on the efficacy and
side effects of these therapies for skin of colour.
Some key differences in the literature include a risk
of increased irritation from emollients due to higher
rates of skin sensitivity, high-dose steroid induced
hypopigmentation, and a lesser response to photo-
therapy or side effects of dyspigmentation and
melasma.
7,9,59,60
There were no guidelines that
discussed these management considerations in
detail, therefore future guidelines should address
this. The overall lack of information in the
guidelines suggests that more research is needed
with a diverse population to further characterise
these differences.
AGREE II appraisal
Less than half of the guidelines met our criteria
for a high-quality guideline based on the AGREE II
assessment. Of the 19 guidelines in the Wang et al
appraisal, 3 were recommended for use in practice
(level A), 11 were recommended with revision
(level B), and 5 were not recommended (level C).
Our reviews, however, used different approaches
to setting the standards for high quality guidelines.
Our cut-off criteria required a score of >50% in
Domain 3 (rigour of development) and 2 other
domains. Wang et al. required scores of >60%
across all domains for level A, and 30–60% for level
B.
50
It is therefore difficult to compare our
appraisal outcomes.
Most guidelines adequately outlined the inten-
ded audience and purpose of the document.
Stakeholder involvement was generally well
documented however lacked all relevant profes-
sional groups who would be involved in the care of
AD such as allied health professionals and nurses.
Moreover, researchers or methodology experts
were rarely included, and only 3 guidelines
included patients/community members in the
development.
16–18
As a chronic condition, a large
component of management for AD includes
patient education and family involvement,
therefore involving the consumers in the
guideline development process is essential to
help create better outcomes for patients.
Guidelines that used systematic grading of evi-
dence such as the Grading of Recommendations
Assessment, Development and Evaluation
(GRADE) tool scored higher,
15–18,25–29,31,32,37–
39,44
as did those with summary tables of
evidence under each recommendation.
15,18,25–
29,31,32,37–39,41,48
The Malaysian, Scottish, and
NICE guidelines scored highly and used the
AGREE II tool in the development process.
16–18
Clarity of presentation was overall done well,
however it was noted that some graphics did not
correspond to the information in the guidelines,
34 Deva et al. World Allergy Organization Journal (2024) 17:100989
http://doi.org/10.1016/j.waojou.2024.100989

such as an image of a palm to describe a fingertip
unit.
37
Most guidelines used clear headings and
summary tables which assist the reader with
identifying key points of information. This was
consistent with the Wang et al appraisal, where
clarity of presentation had the highest average
scores.
50
Applicability had consistently low scoring across
the guidelines. To achieve high scores in applica-
bility according to AGREE II, guidelines had to
describe facilitators and barriers to application,
provide tools on how to put recommendations into
practice, discuss resource implications and pro-
vide monitoring criteria. While many guidelines
had some summary tables, they rarely docu-
mented barriers to application aside from
mentioning factors like steroid phobia, without a
clear plan to overcome this barrier. Furthermore,
cost and resource implications were not discussed
in detail beyond generic statements about AD
having high costs to patients. These guidelines
therefore received scores of 1–3 depending on
their level of detail addressing this domain. Details
of editorial independence were often lacking, and
there was a range of scoring for this domain, with
some guidelines having no funding or conflict of
interest statements, giving a score of 1, and others
having long lists of conflicts of interest without
explaining how the conflicts of interest were
addressed, which received a score of 2. Without
these details, the transparency of the guidelines
decreases. Applicability was similarly the lowest
scoring domain in the Wang et al study.
50
Limitations
While systematic methods were used to search
for the guidelines, a possible limitation would be
missing guidelines due to the wide range of
document types. The AGREE II tool itself is also
subjective and can be interpreted differently by
reviewers. The reviewers noted that the 7-point
scale was challenging to use, especially the dif-
ference between scores of 3 and 4. One strategy
that may help with minimising discrepancies could
be for the reviewers to create their own checklist
for each AGREE II domain for more consistent re-
sults. In addition, while the AGREE II tool can be
useful in guideline development, it does not pro-
vide standardised cut off thresholds, resulting in
differing outcomes of appraisals.
CONCLUSION
The results of this systematic review demonstrate
the strengths and weaknesses of the existing AD
guidelines and highlights areasfor future guidelines
to improve. Management strategies were generally
consistent over the last 5 years. The quality of the
guidelines varied with less than half of the guidelines
meeting the criteria for a high-quality guideline,
indicating that future guidelines would benefitfrom
using a tool such as AGREE II in their development
process. Recommendations regarding AD manage-
ment in skin of colour were lacking across all guide-
lines.There is a strong need for future guidelines to
consider these factors to better reflect the diverse
population of patients with AD.
Abbreviations
AD: Atopic dermatitis; AGREE: Appraisal Guidelines for
Research and Evaluation; PDE4: Phosphodiesterase-4;
UVB: Ultraviolet B; PUVA: Psoralen plus ultraviolet-A radi-
ation; RCT: Randomised controlled trial; TH: T helper;
SCORAD: Scoring Atopic Dermatitis; EASI: Eczema Area
and Severity Index; GRADE: Grading of Recommendations
Assessment, Development and Evaluation
Availability of data and materials
Not applicable.
Author contributions
The lead author, SV and MN conducted the literature
search, data extraction and the AGREE II appraisal. The lead
author initially drafted the publication and all other authors
have contributed substantially to the writing of this
publication.
Ethics approval
Not applicable.
Consent for publication
All authors consent to this work being published.
Conflict of interests
Dr Deva reports no competing interests.
Dr Netting reports no competing interests.
Ms Weidinger reports no competing interests.
Dr Brand reports no competing interests.
A/Prof Loh reports no competing interests.
Dr Vale reports no competing interests.
Funding
The Perth Children’s Hospital Foundation, Grant number
9774.
Volume 17, No. 12, Month 2024 35

Author details
a
James Cook University, 1 James Cook Drive, Douglas,
QLD, 4814, Australia.
b
National Allergy Council, Sydney
NSW, 2000, Australia.
c
Perth Children’s Hospital, Hospital
Avenue, Nedlands, WA 6009, Australia.
d
Perth Children’s
Hospital, Perth WA, 6000, Australia.
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