Atopic dermatitis: the updated practice parameter and beyond

An update to the atopic dermatitis (AD) practice parameter was published in 2013 using an established grading system for determining category of evidence and strength of recommendation. Since the previous update in 2004, a number of seminal observations regarding skin barrier and immune dysregulation in AD have been made with important therapeutic implications. A key addition to the treatment algorithm based on our understanding that normal-appearing skin in patients with AD is not normal is proactive therapy. Studies with both topical steroids and a topical calcineurin inhibitor have shown that in patients with relapsing AD, if they are able to clear or almost clear their eczema, then twice-weekly proactive treatment of normal-appearing skin that tends to flare leads to better disease control. For difficult-to-manage patients, the value of wet wrap therapy is reaffirmed in the practice parameter update. In addition, allergen immunotherapy is now a consideration in select patients with AD and aeroallergen sensitivity. Beyond the practice parameter, novel approaches to filaggrin deficiency are being evaluated. With respect to immune dysregulation, dupilumab, a fully human monoclonal antibody directed at the IL-4 receptor alpha subunit was recently shown to be effective in treating adults with moderate-to-severe AD.