A consensus document on atopic dermatitis in adults has outlined a structured pathway of management to guide GPs including a clear indication of when to refer patients to dermatologists or immunologists.

Lead author Dr Saxon Smith, from the University of Sydney, told the limbic it was also timely to provide guidance on where new systemic medications such as dupilumab will potentially fit.

“There are lots of different options to manage atopic dermatitis and trying to consolidate that into a pathway or process is really important to optimise patient care,” he said.

The panel of experts noted a frustrating lack of specific biomarkers to guide diagnosis or indicate severity of disease.

Instead they recommended a minimum of two patient-related measurements plus a direct measurement of sleep impact in order to gauge disease severity.

Dr Smith said the benefit of tools such as the Patient-Oriented Eczema Measure (POEM) was that they helped cut through the differences between apparent disease severity and the impact on patients and even to their family unit.

“Severe eczema can have different impacts in terms of quality of life. That might be because some patients have learnt how to cope with it but other people can have dramatic impacts on quality of life with smaller amounts of disease.”

He said the significant impact of eczema on sleep and flow-on to patients’ lives was not something that can be measured by looking at the skin.

“It has to be measured by asking the patients and having validated tools to pick up that information. It’s very important to have patient measures as a way to measure severity of disease and atopic dermatitis is no different.”

The consensus recommended the Dermatology Life Quality Index (DLQI) for quantification of treatment success or failure.

In other recommendations:

• Referral to a dermatologist/immunologist is advisable if a person’s dermatitis is not responsive to standard treatment, if it causes significant distress and is interfering with sleep, school or work, if an allergy is suspected and/or if there are recurrent bacterial or viral infections.
• Considerations to escalate therapy: It is important to ascertain whether failure of topical treatment is due to the severity of the disease (lack of efficacy of topical therapy), incorrect usage (dose/application), intolerance or lack of adherence to the treatment when making the decision to begin systemic therapy.
• Choice of phototherapy: Phototherapy (narrowband ultraviolet B [NB-UVB] or ultraviolet A1 [UVA1]) should be considered before the use of other systemic therapy if accessible and practical.
• Use of systemic corticosteroids: Systemic corticosteroids are effective, but associated with short-term and long-term adverse events; use should be limited to bridging, rescue of flares, anticipation of a major life event or in patients with severe AD.