In the final segment 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 2 here, where Dr Lio comments on the guidelines regarding nonsteroidal agents and bleach baths, along with notable recommendations on topical ruxolitinib and elimination diets. 

Remission and proactive therapy 

Dr Lio begins by summarizing the guidelines’ conclusions on remission and proactive therapy, which he considers to be the most important framework shift in treating atopic dermatitis. 

The guidelines strongly recommend the use of proactive therapy with a calcineurin inhibitor or a mid-potency topical corticosteroid in areas that frequently flare as opposed to applying topical treatments only in response to flares. Intermittent use of steroidal or nonsteroidal topical therapies, 2 to 3 times weekly, can potentially maintain remission and reduce the frequency of flareups. 

Systemic therapies 

The guidelines also address systemic options for patients who are refractory to topical therapies, which is usually those with moderate-to-severe disease. These options include biologics such as dupilumab, tralokinumab, and lebrikizumab (currently available in Europe), oral JAK inhibitors upadacitinib, abrocitinib, and baricitinib (currently approved for use with atopic dermatitis outside the US), as well as phototherapy. The biologics and JAK inhibitors are all recommended in their proper context, as is cyclosporine. 

Interestingly, the guidelines recommend against the use of legacy immunosuppressants like azathioprine, methotrexate, and mycophenolate, noting that most well-informed patients prefer to avoid the potential harms and burdens they pose in exchange for modest benefits. 

Similarly, the guidelines recommend against the use of systemic corticosteroids. The panel inferred that patients place a higher value on avoiding harm and poor long-term control of atopic dermatitis than on the uncertain benefit conferred by systemic corticosteroids, with the often transient benefit and low-certainty evidence driving the conditional recommendation. 

Importantly, the overuse of systemic corticosteroids weighed against their routine use for flare management or bridge therapy. 

Exciting time, new guidelines, new ways of thinking about things, and a rich pipeline, which means our work is far from over. 

Dr Lio concludes with his excitement for the guideline’s fresh perspectives and the rich pipeline ahead for atopic dermatitis treatment. 

Watch Part 1 here 

Watch Part 2 here 

Key points: 

• Proactive therapy in areas that frequently flare is strongly recommended to encourage and maintain remission 
• Legacy immunosuppressants and systemic corticosteroids are recommended against, with patients perceiving the risk of adverse effects as outweighing the potential for modest benefits 
• Overuse contributed to the recommendation against treatment with corticosteroids for routine flare management or bridge therapy