Chair Peter A. Lio, MD, prepared useful Practice Aids pertaining to atopic dermatitis for this CME activity titled “Overcoming Challenges in the Management of Moderate to Severe Atopic Dermatitis: Practical Strategies for Selecting Treatment for Pediatric and Adult Patients.” For the full presentation, downloadable Practice Aids, and complete CME information, and to apply for credit, please visit us at https://bit.ly/3uSsDSb. CME credit will be available until September 6, 2022.

1. Atopic Dermatitis Yardstick Flow Diagram1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/XAZ40
a
Poorly or inadequately controlled signs and symptoms of AD.
b
Before stepping up therapy, the patient should be assessed for nonadherence, potential comorbidities, and other factors that might negatively affect response to therapy. Confirmation is needed that the increased level of symptoms is due to AD.
PATIENT PROFILE:
Stepping Up From MILD to MODERATE AD
Symptomatica
despite appropriate use of low- to medium-potency TCS and
following basic management recommendations for skin care, antiseptic
treatment, and avoidance of allergens and irritantsb
Increase TCS dose
or potency
Increase TCS dose
or potency
Add TCI
Add crisaborole
2% ointment
3-month therapeutic trial with
reassessment at 4-8 weeks
Options

2. Atopic Dermatitis Yardstick Flow Diagram1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/XAZ40
Systemic immunosuppressant therapy
Dupilumabd
Phototherapyc
3-month therapeutic
trial with reassessment
at 4-8 weeks
Cyclosporinee
Methotrexatee
Mycophenolate mofetile
Azathioprinee
Corticosteroidsf
PATIENT PROFILE:
Stepping Up From MODERATE to SEVERE AD
Symptomatica
despite an aggressive course of topical prescription therapy
(TCS, TCI, crisaborole) for ≥3 wk; and following basic management
recommendations for skin care, antiseptic treatment, and avoidance of
allergens and irritants—particularly when there is a severe and negative
impact on daily activities, psychosocial health, and QOLb
Refer to specialist
Consider for some
patients acute tx to
help gain control
• Wet wrap therapy
• Hospitalization
a
Poorly or inadequately controlled signs and symptoms of AD. b
Before stepping up therapy, the patient should be assessed for nonadherence, potential comorbidities, and other factors that might negatively affect response to therapy. Confirmation is needed that the increased
level of symptoms is due to AD. c
The patient should be willing and able to commit to phototherapy in terms of cost, convenience, and access. d
Indicated for patients aged ≥18 years with moderate to severe AD. It is the authors' expert opinion that dupilumab has a safety and
efficacy profile that is better than that of immunosuppressive agents or phototherapy; cost and coverage are extremely important considerations. Documentation of the patient's disease severity, prior therapies, including failures, and impact on quality of life might be required.
e
Not FDA approved to treat AD. f
FDA approved to treat AD but not recommended for long-term maintenance. A short course of systemic corticosteroids can help resolve severe symptoms, but exacerbation at discontinuation is common. Systemic corticosteroids also can be
used as cotreatment during the initiation and optimization of phototherapy, other systemic immunosuppressants, and/or dupilumab.
1. Boguniewicz M et al. Ann Allergy Asthma Immunol. 2018;120:10-22.

3. Importance of Patient Education
in Atopic Dermatitis Treatment Selection1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/XAZ40
1. Simpson E et al. J Am Acad Dermatol. 2017;77:623-633.
For patients with moderate to severe atopic dermatitis
(defined by lesional severity and extent and/or significant impact on QOL, including social, emotional,
and school/professional functioning)
Systemic therapy
Choice depends on childbearing capacity, comorbidities
(ie, renal dysfunction, diabetes, alcohol abuse), age,
and preferences (eg, injection vs tablets)
Have you given intensive therapy an adequate trial?
• Appropriate amounts of medium- to high-potency topical anti-inflammatory therapy for 1-4 wk followed by proactive therapy
for maintenance
• Consider wet wrap therapy and soak-and-seal
Does the patient still have persistent, moderate to severe disease/impaired QOL despite intensive topical therapy?
Consider
phototherapy
in selected
patient groups
Is phototherapy unsuccessful,
unsuitable, and/or unavailable?
Have you provided adequate patient education, including
• Avoidance of irritants and known triggers?
• Importance of adherence?
• Optimized topical therapy (under- and overtreatment)?
• Topical steroid phobia?
• Structured educational intervention (eczema school)?
Have you considered alternate diagnoses?
• Have you managed infections?
– Bacterial, viral, yeast
• Have you considered patch testing for contact allergy?
• Is referral to allergy services required for further testing
and optimization of allergic rhinitis/asthma management?

4. Referring Patients With AD to Specialty Care1
Full abbreviations, accreditation, and disclosure information available at PeerView.com/XAZ40
1. https://atopicdermatitis.net/finding-healthcare-provider-doctor-specialist
Dermatologists provide expertise in cases of AD that can be
difficult to diagnose or treat. In certain patients, consultation
with a pediatrician and/or allergist might also help.


There are
frequent
flare-ups
or there is
severe AD
Contact
dermatitis
is suspected

There is a need
for systemic
therapies

There is an
uncertain
diagnosis

Attempts at
managing the
condition have
not controlled
the symptoms

The patient has
AD on the face
that has not
responded to
treatment

AD is causing
significant
psychosocial
disturbances,
including sleep
disruption or
reduced
attendance at
work or school
For patients with chronic conditions such as AD, having a
PCP instead of utilizing an urgent care facility for acute needs
means the patient’s entire history and background
will be taken into consideration.