JOURNAL READING

A Treatment Algorithm for Moderate to

Severe Atopic Dermatitis in Adults
Charles W. Lynde, Marc Bourcier, Melinda Gooderham, Lyn Guenther, Chih-ho Hong, Kim A. Papp,
Yves Poulin, Gordon Sussman, and Ronald Vender

Perceptor:
dr. Arief Effendi Sp.KK
Reffilia Irfa 1718012O97
Vinnyssa Anindita 1718012101
Muty Hardani 1718012088
Firdha Yossi Chani 1718012113
CRITICAL APPRAISAL

VIA PICO
Validity Patients, People, or Problem
Importancy Intervention
Comparison
Applicability
Outcome

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 validity

Title : Clear, informative,

no abbreviation

Correspondency: Clear, complete,

the lead author in the order ahead.
Author details, institution and
correspondency email is also clear

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 Abstract
Abstract : well-
stuctured
Background
Atopic dermatitis (AD) is a chronic, relapsing, pruritic,
inflammatory skin disease. The estimated prevalence of AD is
25% among children and up to 2 to 3% for adults. Although
most adults with AD have mild disease, up to 30% have
moderate to severe disease as assessed by dermatologists
using clinical disease severity scales. It is estimated that
approximately 10% of adult patients have recalcitrant AD
that does not respond adequately to topical anti-
inflammatory treatment and requires phototherapy and/or
systemic therapy with immunosuppressants

This is a follow-up to a previous publication that considered systemic

treatment options for adults with AD. The goal is to provide a patient-
focused approach to the identification and management of adults with AD
who require systemic treatment.
Methods
A working group of clinicians experienced
in managing AD was convened to review
and discuss current evidence on the
identification and clinical management of
adults with moderate to severe AD.
The review also provided a simple
framework for evaluating systemic
treatments for AD.

A literature search was conducted for

articles on guidelines for the management
of AD, clinical outcome measures in AD,
and clinical trials of systemic treatments for
adult AD, including patient demographics
and selection criteria.
Current Treatments
for AD Emollient or moisturiser therapy and topical anti-
inflammatory therapy in the form of calcineurin
inhibitors or corticosteroids are recommended as the
1 first-line treatment for AD.

Systematic reviews of immunosuppressant therapies

2 for AD suggest generally poor-quality evidence to
support their efficacy and safety.

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In 1 single-centre study, a third of patients who had
been treated with systemic therapy had received more
than 1 immunosuppressive agent, with the majority
of discontinuations due to lack of efficacy and/or
intolerability
 Evaluation of Systemic Treatments for AD

There are no effective and safe systemic therapies currently approved for the
long-term management of adults with AD.

Reduction in the signs and symptoms

of disease

Established safety for short- and long-

term use,
Desirable attributes of systemic
treatments for adult AD
Approval by regulatory agencies for
the treatment of AD

Minimal requirements for laboratory

monitoring.

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 • The use of CsA is limited to 1 year of continuous
treatment due to potential nephrotoxicity.
Cyclosporine • Adverse effects of CsA  nephrotoxicity, hypertension,
tremor, malignancy, and etc  require careful monitoring

• The efficacy and safety of AZA are influenced by

individual differences in metabolism  requiring dosage
adjustment according to thiopurine methyltransferase
Azathioprine (TPMT) levels
• Continuous use of AZA requires regular monitoring of
blood counts and liver enzyme

• Most concerned adverse effect  liver toxicity (liver

fibrosis)  in patients with long term use of MTX, liver
Methotrexate biopsy is recommended after a threshold cumulative dose
is administered

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 • Has a more favourable safety profile
Mycophenolate • There are still concerns regarding hematologic
mofetil symptoms and increased susceptibility to infections,
cutaneous malignancy, lymphoma

• Discouraged for continuous or chronic intermittent

use  risk of adrenal suppression, metabolic
Systemic dysregulation, osteoporosis, cataracts, glaucoma,
emotional lability, and risk of rebound
glucocorticoids • Corticosteroids should generally be reserved for
short-term treatment of flares or as transitional
therapy in severe, rapidly progressive disease

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 Diagnosis of AD and Severity

To date, no biomarkers can reliably be used for the diagnosis

of AD.

With regard to assessing disease severity, no assessment scales

can be efficiently applied in a routine clinical setting.

Assessment tools of disease severity and for

measuring outcomes used in some AD clinical
trials,

Six Area, Six Sign

SCORing Atopic
Eczema Area and Investigator’s Global Atopic Dermatitis
Dermatitis (SCORAD)
Severity Index (EASI) Assessment (IGA) (SASSAD) severity
index
score.

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Diagnosis of AD and Severity

These assessment tools have consistently high rates of inter- and

intra-observer variability and the scales themselves are not linear
across the entire range of area of involvement.

These scales are impractical for use in routine practice.

Current evidence-based guidelines for the diagnosis and

management of AD acknowledge the lack of gold standard scale
for routine clinical use to classify patients according to disease
severity.
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The classification of adult patients with AD
according to their response to first-line treatment
strategies:
Patients whose disease is adequately
controlled by topical therapies
Patients with moderate to severe AD
whose disease is not adequately
controlled by topical therapies or in
whom topical treatments are not
appropriate (eg, contraindicated or not
tolerated)
INADEQUATE DISEASE
CONTROL
the absence of meaningful
improvement, as judged
by the clinician and patient
conjointly, within 4 to 8
weeks of initiating topical
therapy with a moderate-
or potent/superpotent
steroid and/or calcineurin
inhibitor, or relapse/flare of
symptoms within 1 week of
discontinuation of topical
therapy.
Moderate to severe AD not adequately controlled with topical therapies (as defined
above)

Pruritus numerical rating scale score ≥4

• The pruritus scale or “itch score” is an 11-point visual analog scale score.
• Scores ≥4 indicate moderate or more severe pruritus.

Body surface area (BSA) ≥10%

Physician’s global assessment (PGA) score ≥3

• consists of a 6-point severity scale assessed by clinicians with scores ≥3 indicating

moderate or more severe disease

Dermatology Life Quality Index (DLQI) score ≥10

• 10-item questionnaire that was developed to measure quality of life in routine clinical
practice in adults with dermatological disorders
• in an analysis of 10 studies in AD, the mean DLQI was 12.2 and the median was 1125 
therefore, we suggest a cutoff ≥10.

Most adults with AD can be
successfully treated with topical Agents
 however, a small proportion requires
phototherapy or systemic treatment.
This artIcle propose a simple algorithm
for classifying adults with moderate to
severe AD based on response to first-
line topical treatments as well as
criteria for selection of patients for
systemic therapy based on 4 clinical
measures that are easy to apply in
routine practice.
 IMPORTANCY
▸ his research is important for
therapeutic evaluation and side effects

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 APPLICABILITY
▸ This article can be a reference that will
help physician or dermatologist to know
about treatment algorithm atopic
dermatitis in adults

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 PICO
▸Problem || Intervention ||
Comparison || Outcome

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0
 🌏 PROBLEM

Atopic dermatitis is a chronic, relapsing, pruritic,

inflammatory skin disease with estimated prevalence 2-3%
among adults. Most adults with AD have mild disease, but
30% have moderate to severe disease.
Adult patients with moderate to severe, recalcitrant AD
that does not respond adequately to topical anti-
inflammatory treatment may requires phototherapy or
systemic therapy

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 📌 INTERVENTION
This article used a traditional review method and
hence, no intervention nor treatment of the subjects
were carried out.
This article put together some current evidence and
guidelines in AD treatment into one unit and form
conclusions

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 👪 COMPARISON

No comparison was made in this article

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 🔑OUTCOME

This article proposed

an algorithm for the
treatment of moderate
to severe AD in adults

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 🔑OUTCOME

This article also proposed practical clinical criteria for selecting adult
candidates for systemic treatment of AD
▸ Moderate to severe AD not adequately controlled with topical therapies
○ absence of meaningful improvement within 4 to 8 weeks of initiating topical therapy with
a moderate-or potent/superpotent steroid and/or calcineurin inhibitor
○ relapse/flare of symptoms within 1 week of discontinuation of topical therapy.
▸ Pruritus numerical rating scale score ≥4
▸ Body surface area (BSA) ≥10%
▸ Physician’s global assessment (PGA) score ≥3
▸ Dermatology Life Quality Index (DLQI) score ≥10

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THANK
YOU