In Part 2 of this Topical Conversations feature with Peter Lio, MD, FAAD, he continues his review of the latest updates to the atopic dermatitis management guidelines from the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force (AAAAI/ACAAI JTF). 

As part of the multidisciplinary guideline panel, Dr Lio offers a dermatologist’s overview of the updated guidelines. 

Watch Part 1 here, where Dr Lio details the guideline design and the recommendations issued for moisturizers and topical therapies. 

Nonsteroidal agents 

In patients with uncontrolled atopic dermatitis that is refractory to moisturization alone, the guidelines state there is high-quality evidence supporting the use of topical calcineurin inhibitors tacrolimus and pimecrolimus. 

Crisaborole, a topical PDE-4 inhibitor, is recommended over usual care alone, supported by high-certainty evidence. While crisaborole is generally safe and well tolerated, patients may experience stinging and burning; considering this, Dr Lio emphasizes the importance of shared decision-making when selecting a treatment course. 

Topical JAK inhibitors 

Notably, the guidelines recommend against the use of the topical JAK inhibitor ruxolitinib, though it is a conditional recommendation with low-certainty evidence. 

While topical ruxolitinib is shown to be safe for use in clinical practice, Dr Lio notes that the perceived safety profile contributed to the recommendation against use. While he does use topical ruxolitinib in his own practice, he notes that he has encountered patients who express concern with the drug’s boxed warning. This recommendation reflects the consideration of the patient voice throughout the development of these guidelines. 

Bleach baths 

The guidelines also cover treatment with dilute bleach baths, with Dr Lio noting that while there is now good evidence that they are not antibacterial, they may still confer benefits. 

The guidelines conclude that dilute bleach baths may be potentially beneficial due to their anti-inflammatory and anti-itch properties and benefits to the skin barrier, but that they are best reserved for cases of moderate to severe atopic dermatitis. 

Elimination diets 

Elimination diets have been a point of contention in AD management. Many patients with AD undergo food allergy testing and elimination diets, but recent understanding challenges this approach, which is that avoiding foods may increase the risk of developing true IGE-mediated food allergies. 

Consequently, the guidelines recommend against the use of elimination diets compared to an unrestricted diet, suggesting that most individuals employing such strategies may experience little to no benefit. This recommendation is seen as a powerful statement from allergists for both clinicians and patients. 

Part 3 

Stay tuned for Part 3 where Dr Peter Lio discusses the updated guidelines for remission and maintenance of remission using proactive therapies to prevent flareups and systemic therapies, including a noteworthy recommendation regarding systemic corticosteroids. 

Watch Part 1 here 

Key points 

• The AAAAI/ACAAI Joint Task Force updates to the clinical guidelines for atopic dermatitis were developed by a multidisciplinary panel and incorporated the expertise of dermatologists 
• The guidelines support the use of nonsteroidal agents but emphasize the importance of shared decision-making when selecting treatment 
• Use of topical ruxolitinib is conditionally recommended against due to patient perception of its safety profile 
• Bleach baths are concluded to be potentially beneficial for cases of moderate to severe atopic dermatitis 
• Elimination diets are recommended against, as they may confer little to no benefit to patients