Peter A. Lio, M.D.Because many patients with atopic dermatitis (AD) may have already seen an allergist, it is helpful for dermatologists to understand there are some salient differences between AD management guidelines issued by the American Academy of Dermatology (AAD) and those from the Joint Task Force of the American College of Asthma, Allergy and Immunology and the American Academy of Asthma, Allergy and Immunology (“JTF”).
Peter A. Lio, M.D., suggests that some of the inconsistencies may be explained by dissimilarity in focus of the two specialties — whereas allergists center more on controlling allergic triggers as an underlying cause for AD, dermatologists are more treatment-oriented and comfortable using systemic medications when needed.
The difference, however, should not be seen as a dividing point between dermatology and allergy, but rather as an opportunity for partnership to achieve the common goal of delivering optimal patient care, says Dr. Lio, assistant professor of clinical dermatology and pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill.
“For the dermatologist, collaboration with an allergist can be especially valuable in situations where allergy is suspected to underlie AD, while allergists often turn to dermatologists to help with patients in need of aggressive therapy for controlling more severe disease,” he says.
Areas of agreement
As a panel member on the JTF AD workgroup and co-author of the JTF guidelines, Dr. Lio shares his insider’s perspective. He notes that the AAD and JTF guidelines agree on certain fundamental tenets for AD management. According to both, topical corticosteroids, topical calcineurin inhibitors, and moisturizers are mainstays of treatment; there is insufficient evidence to recommend specialty moisturizers or prescription barrier creams; when AD is controlled, maintenance (proactive) therapy is useful for preventing a flare; topical antihistamines have no role; and wet wraps are helpful for managing a flare.
Areas of disagreement
“However, there are a number of differences, which is particularly interesting when considered from the perspective that both sets of guidelines were developed based on review of the same evidence,” Dr. Lio says.
A role for vitamin D supplementation is one topic on which the guidelines diverge. Whereas the AAD guidelines say there is not sufficient evidence to recommend its use, the JTF guideline states patients with AD may benefit from vitamin D supplementation. Dr. Lio notes that his personal view is consistent with the JTF guideline.
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“The available evidence in this area goes both ways, but one has to wonder if the conflicting results can be explained by differences in their enrolled populations and if there may be a subgroup of patients who are likely to benefit from vitamin D supplementation and we don’t know yet who they are,” he says.
“Vitamin D supplementation may be worth a try considering it may do some good, is inexpensive, and is unlikely to cause harm,” he says.
The two sets of guidelines also differ in their interpretations of evidence on controlling AD by choosing certain clothing fabrics and laundering practices. The AAD guidelines find evidence in these areas is unclear whereas the JTF guideline supports laundering techniques that might limit patient exposure to chemicals used in clothing manufacturing and residuals from laundry detergents.
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A role of potential dietary triggers is another point on which the two guidelines disagree. The AAD guideline supports a diagnostic elimination diet only if there seems to be a consistent correlation between symptoms and food intake. The allergists are more amenable to this approach, stating evaluation of allergies to milk, eggs, peanut, wheat, and soy could be considered in children <5 years old with persistent moderate-to-severe AD in spite of optimized management and/or if the child has a reliable history of an immediate reaction after ingesting a specific food.
A reflection of specialties
Differences in treatment recommendations also reflect the unique expertise of the two specialties. The AAD guideline say injection immunotherapy cannot be routinely recommended whereas according to the JTF, this modality can be considered in selected patients with aeroallergen sensitivity.
In the allergy guidelines a systemic antihistamine is identified as potentially beneficial for relieving itch associated with AD in some patients, whereas the AAD guideline concludes there is insufficient evidence to recommend such use.
“The available evidence is pretty convincing that an antihistamine is not helpful for relieving itch in AD, and that is supported by my anecdotal experience discontinuing anthistamines in patients that were using them on their own or based on their allergist’s recommendation,” Dr. Lio says.