Updated Guidelines for Atopic Dermatitis (Eczema)

       Almost a third of all primary care pediatric visits involve a dermatologic presentation.  As atopic dermatitis represents the most common inflammatory pediatric skin disease, those of us on the front lines of pediatric care ought to familiarize ourselves with the most recent atopic dermatitis (eczema) practice guidelines, published this past December (2023) by the Joint Task Force on Practice Parameters of the American Academy of Asthma, Allergy and Immunology/American College of Asthma, Allergy and Immunology.  The new guidance represents the academies’ first update on the management of atopic dermatitis in over a decade, and there are some key changes that deserve consideration – including the recommendation of bleach baths for the management of moderate and severe disease.  

It should surprise no one that the updated guidelines include therapies that had not yet been approved for children at the time of their last publication in 2012 – such as topical PDE4 inhibitors, topical and systemic JAK inhibitors, and systemic IL-4 receptor antagonists.  These evidence-based changes, of course, represent the advance of research and technology – but standing right alongside these biotech inventions is the first-ever inclusion of bleach baths (a regimen that precedes many of the other treatments by almost a century, and requires no prescription or prior authorization from insurance companies).

What is to follow is a review of the five major areas – dilute bleach baths; dietary avoidance/elimination; topical treatments; allergen immunotherapy; and systemic treatments – in which the 2023 Joint Task Force (JTF) updated its guidelines for the treatment of atopic dermatitis, arranged in order of relevance to primary care providers.

 

Bleach baths as an additive therapy for patients with moderate-to-severe disease.  The JTF concluded that bleach (sodium hypochlorite) baths would reduce disease severity by at least 50% in one-third of patients with atopic dermatitis, and so recommended it as an adjunct to other therapies in children with moderate-to-severe disease.  But it should be noted that the stated reason for the JTF not recommending bleach baths for mild disease was the relative burden of getting into a tub of dilute sodium hypochlorite, and not its lack of efficacy.  This issue disappears, of course, when the bleach bath is introduced as a gel formulation wash or cleanser such as the CLn Body Wash, the CLn Sport Wash, and the CLn 2-in-1 Gentle Wash & Shampoo – cleansers and shampoos formulated with sodium hypochlorite and surfactants, thereby obviating the need for drawing up a bath, and allowing the patient to take the cleansers into the shower with them.

            Another reason that the JTF did not include mild disease in its recommendation was the lack of universal access to a bathtub – another issue that goes away when the bleach bath comes to the patient in a bottle with a convenient squeeze-top cap, as all the CLn washes do.  And the JTF made a point that the recommendation of a bleach bath should come with written instructions provided by the pediatrician on the right type and concentration of bleach – yet another issue that a standardized commercial preparation renders unnecessary (and, in fact, there are written instructions on how to use the hypochlorite cleansers on the back of the CLn bottles, which saves the pediatrician the time of composing and distributing literature).

            Taken together, the various conveniences of a “bleach bath in a bottle” formulation, in light of the new JTF recommendations, offers patients an OTC solution that avoids modulation of the immune system.

 

            Recommendation against elimination diets in patients of all disease severity.  The JTF concluded that most individuals pursuing a food allergen elimination diet would experience little to no benefit in the severity of their atopic dermatitis.  In fact, the JTF remarked that elimination diets might produce more harm than good, as early exposure to possible food allergens in childhood actually decreases the incidence of food allergies, and the more severe consequences that might come along with them, without putting a child at the risk of nutritional deficiencies that might result from dietary restriction.  This is a welcome revision to the JTF guidelines:  similar to the dilute bleach recommendation, it offers patients practical guidance that does not require a prescription and is focused on an approach that makes it easier for parents to care for their children.

 

            Topical treatments for the management of atopic dermatitis.  It should be noted that at the very top of these JTF guidelines is the recommendation against prescription moisturizers and the endorsement of OTC moisturizers.  This is a third example of the JTF introducing a clinically significant convenience to the care of atopic dermatitis patients and placing an important management modality in the scope of primary care.  Moisturizers, of course, come in numerous accessible and effective OTC formulations.  For the clinician looking to pair a moisturizer with bleach in accordance with guidelines, the CLn 2-in-1 Gentle Wash & Shampoo (which contains the humectant glycerin) would represent a practical choice – as would the adjunctive use of the CLn Facial Moisturizer, which contains occlusive ceramides and emollient niacinamides.

            The updated guidelines also affirm the use of topical corticosteroid applications (with a preference toward once daily dosing), as well as the routine use of calcineurin inhibitors, PDE4 inhibitors and JAK inhibitors in disease refractory to moisturizers.

 

            Allergen immunotherapy for moderate-to-severe disease.  The guidelines suggest immunotherapy for those who are refractory or intolerant of topical therapy; exclude patients with mild disease; and include the possibility of both sublingual and subcutaneous immunotherapy.  Of note, the efficacy of immunotherapy acknowledged by the JTF was only slightly greater than that of bleach baths, and with a much higher adverse event profile.  Immunotherapy, of course, would require consultation with an allergist, residing outside the scope of practice of most pediatricians.

            Systemic treatments for moderate-to-severe disease.  Many of the recommendations were against the use of small molecule immunosuppressants (with the exception of oral JAK inhibitors).  Ultraviolet light and monoclonal antibodies were recommended for those with disease refractory to topical treatments – but would obviously require specialty consultation.

 

Reference:

 Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE– and Institute of Medicine–based recommendations

https://www.annallergy.org/article/S1081-1206(23)01455-2/fulltext

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