JOURNAL READING

A Treatment Algorithm for Moderate to Severe Atopic

Dermatitis in Adults

Pembimbing: dr. Arif Effendi, Sp. KK

Amira Puri Zahra

Atika Marcherya
Dwi Jayanti Tri Lestari
Elizabeth Ruttina H
Niken Rahmatia
Sabrina Fazrieza
SMF ILMU KULIT DAN KELAMIN
RUMAH SAKIT UMUM DAERAH DR. H. ABDUL
MOELOEK
BANDAR LAMPUNG
2019
1
 BACKGROUND
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 (eg,
cyclosporine A [CsA],
methotrexate [MTX],
azathioprine [AZA], or
mycophenolate mofetil)
None of these
systemic therapies are
approved in Canada
for the treatment of
AD, and moreover,
high-quality,
randomised, controlled
trials are lacking to
support their use in AD
 BACKGROUND

Recent clinical trials in

AD have uncovered
new insights on the This is a follow-up
immunopathogenesis to a previous
of the disease and publication that
identified potential consid- ered
targets for treatment systemic
and opportunities for treatment options
patient stratification for adults with AD
 METHODS
● A working group of clinicians experienced in treating AD -> in November 2016 to
discuss unmet patient and clinician needs related to the management of adults
with AD who require systemic therapy

● Current evidence and recent guidelines were reviewed as a foundation for a

practical approach to the identification and treatment of patients with AD
requiring systemic therapy.

● The review also provided a simple framework for evaluating systemic treatments
for AD.

● A literature search was conducted for articles on guide- lines 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 as
the first-line treatment for AD
● 10% of patients fail to respond to such treatment and require phototherapy
or systemic anti- inflammatory agents.
● Systematic reviews of immunosuppressant therapies for AD suggest
generally poor-quality evidence to support their efficacy and safety.
 Diagnosis Atopic Dermatitis (Hanifin-Rajka)

1
2
SCORAD Index
Patient Selection for Systemic Treatment

Classification of adult patients with AD according to their response to firstline

treatment strategies:

1. Patients whose disease is adequately controlled by topical therapies

2. Patients with moderate to severe AD whose disease is not adequately

controlled by topical therapies or in whom topical treatments are not
appropriate (eg, con-traindicated or not tolerated)
Inadequate disease control was defined by this working group as the absence of meaningful improvement, as judged
by the clinician and patient conjointly, within 4 to 8 weeks of initiating topical therapy with a moderateor
potent/super-potent steroid and/or calcineurin inhibitor, or relapse/flare of symptoms within 1 week of
discontinuation of topical therapy.

With criteria for selecting adult candidates for systemic treatment of AD:

1. Moderate to severe AD not adequately controlled with topical therapies (as defined above)

2. Pruritus numerical rating scale score ≥4

3. Body surface area (BSA) ≥10%

4. Physician’s global assessment (PGA) score ≥3

5. Dermatology Life Quality Index (DLQI) score ≥10

Evaluation of systemic treatments for AD
systemic immunosuppressant therapies that are used off-label for the management of AD should be
considered as salvage therapies whose use is limited by short and longterm toxicity.

❑ Corticosteroid is generally limited to 1 year of continuous treatment due to potential

nephrotoxicity and other adverse effects require careful monitoring (needing regular
monitoring of blood counts and liver enzymes in all patient)

❑ Liver toxicity can also be a concern with MTX; in patients with psoriasis, liver biopsy is
recommended after a threshold cumulative dose is administered, but the rel-evance of
monitoring for liver toxicity in patients with AD remains unknown. Noninvasive monitoring
of liver fibrosis is becoming more widely available, and study supports its utility in
monitoring patients with AD receiving MTX.

❑ Mycophenolate mofetil has a more favourable safety profile, but there are concerns
regarding hematologic symptoms and increased susceptibility to infections, cutaneous
malignancy, lymphoma, and an association with progressive multifocal
leukoencephalopathy.

❑ Systemic glucocorticoids are discouraged for continuous or chronic intermittent use due to
their associated risk of adrenal suppression, hypertension, metabolic dysregulation,
osteopenia/osteoporosis, avascular necrosis of bone, purpura, cataracts, glaucoma,
❏ Corticosteroids should be considered an intervention, not a treatment, and
their use should generally be reserved for shortterm treatment of flares or
as transitional therapy in severe, rapidly progressive disease.
❏ These data suggest that current systemic treatments do not adequately
meet the needs of most adult patients with AD who fail to respond to
topical management strategies and/or phototherapy.
Clinical Algorithm for Treatment of Moderate to Severe AD

A practical algorithm to guide the management of adults with moderate to severe

AD. It should be noted that this algorithm focuses on treat-ment to suppress the
inflammation associated with AD rather than for the management of secondary
infections or for the sole purpose of treating pruritus;effective treatment of the
underlying inflammation of AD typically results in improvement in itching
 Limitations Conclusions
This review focuses on
adult patients with Most adults with AD
moderate to severe AD can be successfully
and the suggested treated with topical
selection criteria and agents; however, a
clinical management small proportion
algorithm should not be requires phototherapy
applied to paediatric or systemic treatment.
populations.
 Validity

Clear and informative, less that 20 words

Correspondency : Clear and complete. Authors detail,

Institution and correspondences clear.
 Validity

Abstract:
Well structured, there are keyword and less than 200 words
 Importancy

Atopic dermatitis (AD) is Current evidence and

a common and chronic The goal is to provide
recent guidelines a patient-focused
inflammatory skin were reviewed as a
disease. Approximately approach to the
foundation for a identification and
10% of adults with practical approach to management of
AD do not respond the identification and adults with AD who
adequately to topical treatment of patients require systemic
therapies and require with AD requiring
phototherapy and/or systemic therapy. treatment.
systemic therapy.
 APPLICABILITY

This journal can be applied because the author

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.
PICO
 Problem
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 (eg, cyclosporine A [CsA], methotrexate [MTX], azathioprine [AZA], or mycophenolate
mofetil)

To provide patient-focused approach to the identification and management of adults with AD who require
systemic treatment.
 Intervention
A working group of clinicians experienced in treating AD convened in November 2016 to discuss
unmet patient and clinician needs related to the management of adults with AD who require systemic
therapy

Current evidence and recent guidelines were reviewed as a foundation for a practical approach to the
identification and treatment of patients with AD requiring systemic therapy

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.
 Comparison

• Current evidence and recent guidelines were reviewed as a foundation for a practical approach to
the identification and treatment of patients with AD requiring systemic therapy.

• Evaluating systemic treatments for AD.

THANK YOU