FROM THE ACADEMY
Guidelines of care for the management
of atopic dermatitis
Section 1. Diagnosis and assessment of atopic dermatitis
Work Group: Co-chair, Lawrence F. Eichenfield, MD,a Wynnis L. Tom, MD,a Sarah L. Chamlin, MD, MSCI,b
Steven R. Feldman, MD, PhD,c Jon M. Hanifin, MD,d Eric L. Simpson, MD,d Timothy G. Berger, MD,e
James N. Bergman, MD,f David E. Cohen, MD,g Kevin D. Cooper, MD,h Kelly M. Cordoro, MD,e
Dawn M. Davis, MD,i Alfons Krol, MD,d David J. Margolis, MD, PhD,j Amy S. Paller, MS, MD,k
Kathryn Schwarzenberger, MD,l Robert A. Silverman, MD,m Hywel C. Williams, PhD,n Craig A. Elmets, MD,o
Julie Block, BA,p Christopher G. Harrod, MS,q Wendy Smith Begolka, MBS,q and
Co-chair, Robert Sidbury, MDr
San Diego, San Francisco, and San Rafael, California; Chicago and Schaumburg, Illinois; Winston-Salem,
North Carolina; Portland, Oregon; Vancouver, British Columbia, Canada; New York, New York;
Cleveland, Ohio; Rochester, Minnesota; Philadelphia, Pennsylvania; Burlington, Vermont; Fairfax,
Virginia; Nottingham, United Kingdom; Birmingham, Alabama; and Seattle, Washington
Atopic dermatitis (AD) is a chronic, pruritic, inflammatory dermatosis that affects up to 25% of children
and 2% to 3% of adults. This guideline addresses important clinical questions that arise in the
management and care of AD, providing updated and expanded recommendations based on the available
evidence. In this first of 4 sections, methods for the diagnosis and monitoring of disease, outcomes
measures for assessment, and common clinical associations that affect patients with AD are
discussed. Known risk factors for the development of disease are also reviewed. ( J Am Acad Dermatol
2014;70:338-51.)
Key words: assessment scales; atopic dermatitis; biomarkers; clinical associations; criteria; diagnosis;
risk factors.
DISCLAIMER
regarding the propriety of any specific therapy
Adherence to these guidelines will not ensure
must be made by the physician and the patient in
successful treatment in every situation. In addition,
light of all the circumstances presented by the
these guidelines should not be interpreted as
individual patient and the known variability and
setting a standard of care, or be deemed inclusive
biologic behavior of the disease. This guideline
of all proper methods of care nor exclusive of
reflects the best available data at the time the
other methods of care reasonably directed to
guideline was prepared. The results of future
obtaining the same results. The ultimate judgment
From the Division of Pediatric and Adolescent Dermatology,a Rady Hospitals NHS Trust, Nottingham; Department of Dermatolo-
Children’s Hospital San Diego; Department of Dermatology,b gy,o University of Alabama at Birmingham; National Eczema
Ann and Robert H. Lurie Children’s Hospital of Chicago; Association,p San Rafael; American Academy of Dermatology,q
Department of Dermatology,c Wake Forest University Health Schaumburg; and the Department of Dermatology,r Seattle
Sciences, Winston-Salem; Department of Dermatology,d Ore- Children’s Hospital.
gon Health and Science University; Department of Dermatolo- Funding sources: None.
gy,e University of California San Francisco; Department of The authors’ conflicts of interest/disclosure statements appear at
Dermatology and Skin Science,f University of British Columbia; the end of the article.
Ronald O. Perelman Department of Dermatology,g New York Accepted for publication October 5, 2013.
University School of Medicine; Department of Dermatology,h Reprint requests: Wendy Smith Begolka, MBS, American Academy
Case Western University, Cleveland; Department of Dermato- of Dermatology, 930 E Woodfield Rd, Schaumburg, IL 60173.
logy,i Mayo Clinic, Rochester; Department of Biostatistics and E-mail: wsmithbegolka@aad.org.
Epidemiology,j University of Pennsylvania School of Medicine; Published online December 2, 2013.
Department of Dermatology,k Northwestern University Fein- 0190-9622/$36.00
berg School of Medicine; Division of Dermatology,l Fletcher Ó 2013 by the American Academy of Dermatology, Inc.
Allen Health Care, Burlington; private practice,m Fairfax; Centre http://dx.doi.org/10.1016/j.jaad.2013.10.010
of Evidence-Based Dermatology,n Nottingham University
338
, J AM ACAD DERMATOL Eichenfield et al 339
VOLUME 70, NUMBER 2
disclosure of interests that was updated and re-
Abbreviations used: viewed for potential relevant conflicts of interest
AAD: American Academy of Dermatology throughout guideline development. If a potential
AD: atopic dermatitis conflict was noted, the work group member recused
ADHD: attention deficit hyperactivity disorder
CDLQI: Children’s Dermatology Life Quality Index him or herself from discussion and drafting of
DFI: Dermatitis Family Impact recommendations pertinent to the topic area of the
DLQI: Dermatology Life Quality Index disclosed interest.
EASI: Eczema Area and Severity Index
FLG: filaggrin An evidence-based model was used and evidence
GREAT: Global Resource for Eczema Trials was obtained using a systematic search of PubMed, the
IGA: Investigator’s Global Assessment Cochrane Library, and the Global Resource for Eczema
IgE: immunoglobulin E
IL: interleukin Trials (GREAT)1 databases from November 2003
ISAAC: International Study of Asthma and Allergies through November 2012 for clinical questions ad-
in Childhood dressed in the previous version of this guideline
MDC: macrophage-derived chemoattractant
POEM: Patient-Oriented Eczema Measure published in 2004, and from 1964 to 2012 for all newly
SASSAD: Six Area, Six Sign Atopic Dermatitis identified clinical questions as determined by the work
SCORAD: SCORing Atopic Dermatitis group to be of importance to clinical care. Searches
SORT: strength of recommendation taxonomy
TARC: thymus and activation-regulated chemokine were prospectively limited to publications in the
TISS: Three-Item Severity Scale English language. MeSH terms used in various
UK: United Kingdom combinations in the literature search included: atopic
dermatitis, atopic eczema, diagnosis, diagnostic,
severity course, assessment, biomarkers, outcomes
studies may require revisions to the recommenda- measures, morbidity, quality of life, appearance, co-
tions in this guideline to reflect new data. morbidity, food allergy, allergic rhinitis, asthma, can-
cer, sleep, growth effects, developmental effects,
SCOPE behavioral, psychological, attention deficit hyperac-
This guideline addresses the diagnosis and tivity disorder (ADHD), treatment, and outcome. A
assessment of pediatric and adult atopic dermatitis total of 1417 abstracts were initially assessed for
(AD; atopic eczema) of all severities. Other forms of possible inclusion. After removal of duplicate data,
dermatitis, such as irritant dermatitis and allergic 292 were retained for final review based on relevancy
contact dermatitis in those without AD, are outside and the highest level of available evidence for the
of the scope of this document. Recommendations on outlined clinical questions. Evidence tables were
AD treatment and management are subdivided into 4 generated for these studies and used by the
sections given the significant breadth of the topic and work group in developing recommendations. The
to update and expand on the clinical information and Academy’s previously published guidelines on AD
recommendations previously published in 2004. This were also evaluated, as were other current published
document is the first section in the series and covers guidelines on AD.2-5
methods for diagnosis and monitoring of AD, disease The available evidence was evaluated using a uni-
severity and quality of life scales for outcomes mea- fied system called the Strength of Recommendation
surement, and common clinical associations that Taxonomy (SORT) developed by editors of US family
affect patients. A discussion on known risk factors medicine and primary care journals (ie, American
for the development of AD is also presented. The Family Physician, Family Medicine, Journal of Family
second guideline in the series will address the man- Practice, and BMJ USA).6 Evidence was graded using a
agement and treatment of AD with pharmacologic 3-point scale based on the quality of study methodol-
and nonpharmacologic topical modalities; the third ogy (eg, randomized control trial, case control,
section will cover phototherapy and systemic treat- prospective/retrospective cohort, case series, etc) and
ment options; and the fourth section will address the the overall focus of the study (ie, diagnosis, treatment/
minimization of disease flares, educational interven- prevention/screening, or prognosis) as follows:
tions, and use of adjunctive approaches. I. Good-quality patient-oriented evidence (ie, evi-
dence measuring outcomes that matter to
METHOD patients: morbidity, mortality, symptom improve-
A work group of recognized AD experts was ment, cost reduction, and quality of life).
convened to determine the audience and scope of II. Limited-quality patient-oriented evidence.
the guideline, and to identify important clinical III. Other evidence, including consensus guidelines,
questions in the diagnosis and assessment of AD opinion, case studies, or disease-oriented evidence
(Table I). Work group members completed a (ie, evidence measuring intermediate, physiologic,
