F ROM THE
ACADEMY
天造地设的意思
Guidelines of care for the management
of atopic dermatitis
Section1.Diagnosis and asssment of atopic dermatitis
深圳游学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,MD r
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 to25%of children and2%to3%of adults.This guideline address important clinical questions that ari in the management and care of AD,providing updated and expanded recommendations bad on the available evidence.In thisfirst of4ctions,methods for the diagnosis and monitoring of dia,outcomes measures for asssment,and common clinical associations that affect patients with AD are discusd.Known risk factors for the development of dia are also reviewed.(J Am Acad Dermatol 2014;70:338-51.)
Key words:asssment scales;atopic dermatitis;biomarkers;clinical associations;criteria;diagnosis;
risk factors.
DISCLAIMER
Adherence to the guidelines will not ensure successful treatment in every situation.In addition, the guidelines should not be interpreted as tting a standard of care,or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results.The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances prented by the individual patient and the known variability and biologic behavior of the dia.This guideline reflects the best available data at the time the guideline was prepared.The results of future
From the Division of Pediatric and Adolescent Dermatology,a Rady Children’s Hospital San Diego;Department of Dermatology,b Ann and Robert H.Lurie Children’s Hospital of Chicago;
Department of Dermatology,c Wake Forest University Health Sciences,Winston-Salem;Department of Dermatology,d Ore-gon Health and Science University;Department of Dermatolo-gy,e University of California San Francisco;Department of Dermatology and Skin Science,f University of British Columbia;
四川大学历年录取分数线Ronald O.Perelman Department of Dermatology,g New York University School of Medicine;Department of Dermatology,h Ca Western University,Cleveland;Department of Dermato-l
ogy,i Mayo Clinic,Rochester;Department of Biostatistics and Epidemiology,j University of Pennsylvania School of Medicine;
Department of Dermatology,k Northwestern University Fein-berg School of Medicine;Division of Dermatology,l Fletcher Allen Health Care,Burlington;private practice,m Fairfax;Centre of Evidence-Bad Dermatology,n Nottingham University
Hospitals NHS Trust,Nottingham;Department of Dermatolo-gy,o University of Alabama at Birmingham;National Eczema Association,p San Rafael;American Academy of Dermatology,q Schaumburg;and the Department of Dermatology,r Seattle Children’s Hospital.
Funding sources:None.
The authors’conflicts of interest/disclosure statements appear at the end of the article.
Accepted for publication October5,2013.
Reprint requests:Wendy Smith Begolka,MBS,American Academy of Dermatology,930E Woodfield Rd,Schaumburg,IL60173.
环境污染作文E-mail:wsmithbegolka@aad.
Published online December2,2013.
0190-9622/$36.00
Ó2013by the American Academy of Dermatology,Inc.
dx.doi/10.1016/j.jaad.2013.10.010
338
studies may require revisions to the recommenda-tions in this guideline to reflect new data. SCOPE
This guideline address the diagnosis and asssment of pediatric and adult atopic dermatitis (AD;atopic eczema)of all verities.Other forms of dermatitis,such as irritant dermatitis and allergic contact dermatitis in tho without AD,are outside of the scope of this document.Recommendations on AD treatment and management are subdivided into4 ctions given the significant breadth of the topic and to update and expand on the clinical information and recommendations previously published in2004.This document is thefirst ction in the ries and covers methods for diagnosis and monitoring of AD,dia verity and quality of life scales for outcomes mea-surement,and common clinical associations that affect patients.A discussion on known risk factors for the development of AD is also prented.The cond guideline in the ries will address the man-agement and treatment of AD with pharmacologic and nonpharmacologic topical modalities;the third ction will cover phototherapy and systemic treat-ment options;and the fourth ction will address the minimization of diaflares,educational interven-tions,and u of adjunctive approaches. METHOD
A work group of recognized AD experts was convened to determine the audience and scope of the guideline,and to identify important clinical questions in the diagnosis and asssment of AD (Table I).
Work group members completed a disclosure of interests that was updated and re-viewed for potential relevant conflicts of interest throughout guideline development.If a potential conflict was noted,the work group member recud him or herlf from discussion and drafting of recommendations pertinent to the topic area of the disclod interest.
An evidence-bad model was ud and evidence was obtained using a systematic arch of PubMed,the Cochrane Library,and the Global Resource for Eczema Trials(GREAT)1databas from November2003 through November2012for clinical questions ad-dresd in the previous version of this guideline published in2004,and from1964to2012for all newly identified clinical questions as determined by the work group to be of importance to clinical care.Searches were prospectively limited to publications in the English language.MeSH terms ud in various combinations in the literature arch included:atopic dermatitis,atopic eczema,diagnosis,diagnostic, verity cour,asssment,biomarkers,outcomes measures,morbidity,quality of life,appearance,co-morbidity,food allergy,allergic rhinitis,asthma,can-cer,sleep,growth effects,developmental effects, behavioral,psychological,attention deficit hyperac-tivity disorder(ADHD),treatment,and outcome.A total of1417abstracts were initially assd for possible inclusion.After removal of duplicate data, 292were retained for final review bad on relevancy and the highest level of available evidence for t
he outlined clinical questions.Evidence tables were generated for the studies and ud by the work group in developing recommendations.The Academy’s previously published guidelines on AD were also evaluated,as were other current published guidelines on AD.2-5
meryThe available evidence was evaluated using a uni-fied system called the Strength of Recommendation Taxonomy(SORT)developed by editors of US family medicine and primary care journals(ie,American Family Physician,Family Medicine,Journal of Family Practice,and BMJ USA).6Evidence was graded using a 3-point scale bad on the quality of study methodol-ogy(eg,randomized control trial,ca control, prospective/retrospective cohort,ca ries,etc)and the overall focus of the study(ie,diagnosis,treatment/ prevention/screening,or prognosis)as follows:
I.Good-quality patient-oriented evidence(ie,evi-
dence measuring outcomes that matter to patients:morbidity,mortality,symptom improve-ment,cost reduction,and quality of life).
II.Limited-quality patient-oriented evidence.
济南培训III.Other evidence,including connsus guidelines, opinion,ca studies,or dia-oriented evidence (ie,evidence measuring intermediate,physiologic,
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or surrogate end points that may or may not reflect improvements in patient outcomes).
Clinical recommendations were developed bad on the best available evidence.The are ranked as follows:
A.Recommendation bad on consistent and
good-quality patient-oriented evidence.
B.Recommendation bad on inconsistent or
limited-quality patient-oriented evidence.
C.Recommendation bad on connsus,opinion,
ca studies,or dia-oriented evidence.
hardware是什么意思In situations where documented evidence-bad data are not available,we have ud expert opinion to generate our clinical recommendations.
This guideline has been developed in accordance with the American Academy of Dermatology(AAD)/ AAD Association Administrative Regulations for Evidence-bad Clinical Practice Guidelines(version approved May2010),which includes the opportunity for review and comment by the entire AAD member-ship and final review and approval by the AAD Board of Directors.7This guideline will be considered current for a period of5years from the date of publication,unless reaffirmed,updated,or retired at or before that time.
DEFINITION
什么是idAD is a chronic,pruritic inflammatory skin dia that occurs most frequently in children,but also affects many adults.It follows a relapsing cour.AD is often associated with elevated rum immuno-globulin(IgE)levels and a personal or family history of type I allergies,allergic rhinitis,and asthma. Atopic eczema is synonymous with AD. INTRODUCTION
AD ont is most common between3and6 months of age,with approximately60%of patients developing the eruption in thefirst year of life and 90%by5years of age.8,9While the majority of affect
ed individuals have resolution of dia by adulthood,10%to30%do not,and a smaller percentage first develop symptoms as adults.10AD has a complex pathogenesis involving genetic, immunologic,and environmental factors that lead to a dysfunctional skin barrier and dysregulation of the immune system.Notable clinical findings include erythema,edema,xerosis,erosions/excoriations, oozing and crusting,and lichenification,but the vary by patient age and chronicity of lesions.Pruritus is a hallmark of the condition that is responsible for much of the dia burden borne by patients and their families.优路教育网
DIAGNOSIS
The diagnosis of AD is made clinically and is bad on historical features,morphology and distribution of skin lesions,and associated clinical signs.Formal ts of criteria have been developed by various groups to aid in classification.
One of the earliest and most recognized ts of diagnostic criteria is the1980Hanifin and Rajka criteria,11which requires that3of4major criteria and 3of23minor criteria be met.While comprehensive and often ud in clinical trials,such a large number of criteria are unwieldy for u in clinical practice. Some of the minor criteria have been noted to be poorly defined or nonspecific,such as pity
riasis alba, while others,such as upper lip cheilitis and nipple eczema,are quite specific for AD but uncommon.11,12Several international groups have propod modifications to address the limitations (eg,Kang and Tian criteria,International Study of Asthma and Allergies in Childhood[ISAAC] criteria).13-16The United Kingdom(UK)Working Party,in particular,systematically distilled the Hanifin and Rajka criteria down to a core t that is suitable for epidemiologic/population-bad studies and that can be ud by nondermatologists.The consist of1mandatory and5major criteria and do not require any laboratory testing.Both the Hanifin and Rajka and UK Working Party diagnostic schemes have been validated in studies and tested in veral different populations.12,13,15,17-23
A2003connsus conference spearheaded by the American Academy of Dermatology suggested revid Hanifin and Rajka criteria that are more streamlined and additionally applicable to the full range of ages affected.24While this t has not been assd in validation studies,it is felt by the current work group that an adaptation of this pragmatic approach for diagnosing AD in infants,children, and adults is well suited for u in the clinical tting
Table I.Clinical questions ud to structure the evidence review for the diagnosis and asssment of atopic dermatitis
d What ar
e the most valid and reliable methods for
diagnosing atopic dermatitis?*
d What ar
e the most uful tools to asss the verity
and cour of atopic dermatitis?*
d What ar
e the patient-and dia-specific outcome
measures ud to determine the relative effectiveness of a given treatment for atopic dermatitis?*
d What common clinical associations may affect patients
with atopic dermatitis?*
d What ar
e the epidemiologic risk factors associated with
atopic dermatitis?*
*Indicates new clinical questions.J A M A CAD D ERMATOL
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(Box 1).The original UK criteria cannot be applied to very young children,although revisions to include infants have since been propod.25-27
The recommendation for the diagnosis of AD is shown in Table II ,and the strength of the recommen-dation is displayed in Table III .AD should be differ-entiated from other red,scaly skin conditions.It is often difficult to parate AD from borrheic derma-titis in infancy,and the 2conditions may overlap in this age group.AD usually spares the groin and axillary regions,while borrheic dermatitis affects the areas and tends not to be pruritic.Particularly if not responding to therapy,the diagnosis of AD
should be re-reviewed and other disorders considered,in-cluding more rious nutritional,metabolic,and im-munologic conditions in children and cutaneous T-cell lymphoma in adults.Allergic contact dermatitis may be both an alternative diagnosis to AD and/or an exacerbator of AD in some individuals (further dis-cusd in ction 4of the guideline ries).
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label是什么意思BIOMARKERS
The diagnosis of AD remains clinical,becau there is currently no reliable biomarker that can distinguish the dia from other entities.The most commonly associated laboratory feature,an elevated total and/or allergen-specific rum IgE level,is not prent in about20%of affected individuals.28Some denote‘‘extrinsic’’and‘‘intrinsic’’groups of dia bad on the prence or abnce of IgE elevation, but whether the are true variants remains contro-versial.Some individuals will later develop elevated IgE levels,and recent knowledge of skin barrier defects and studies on epicutaneous nsitization suggest that elevated IgE may be a condary phenomenon.28Elevated allergen-specific IgE levels are also nonspecific,becau they are found in55% of the US general population.29Although the total IgE level does tend to vary with dia verity,it is not a reliable indicator,becau some individuals with vere dia have normal values,and IgE may also be elevated in multiple nonatopic conditions (eg,parasitic infection and cert
ain cancers and autoimmune dias).28,30,31Increas in tissue mast cells and peripheral eosinophil counts have also been evaluated,but with similar inconsistent association.30,32-34
Discovery of new T-lymphocyte subts and novel cytokines and chemokines have generated a myriad of additional potential biomarkers.The include rum levels of CD30,macrophage-derived chemoattractant(MDC),interleukins(IL)-12,-16, -18,and-31,and thymus and activation-regulated chemokine(TARC).Some have shown a correlation with AD dia verity using the SCORing Atopic Dermatitis(SCORAD)index and other verity scales.35-40But to date,none have shown reliable nsitivity or specificity for AD to support general clinical u for diagnosis or monitoring.Most studies suffer from a small cohort size and involve lection from tertiary care centers with more vere dia rather than from general populations.Few have compared levels in AD with that in other eczematous conditions or other atopic conditions to asss whether the biomarker is a specific indicator for AD.
Markers for prognosis are also inconsistent, although high total rum IgE levels andfilaggrin (FLG)gene null mutations do tend to predict a more vere and protracted cour of dia (discusd further below in‘‘Risk factors for dia development’’).9,28,41,42Recommendations for the u of biomarkers in the asssment of AD are shown in Table IV,and the strength of the recom-
mendations are summarized in Table III. DISEASE SEVERITY AND CLINICAL OUTCOMES ASSESSMENT
Dia verity scales
For the measurement of dia verity, 28different scales were identified,without a single gold standard emerging.43-56They u various methods that include grid patterns and objective dia features and extent,and some scales incorporate subjective dia features.The most commonly ud dia verity scales are the SCORAD index,the Eczema Area and Severity Index(EASI),Investigator’s Global Asssment (IGA),and the Six Area,Six Sign Atopic Dermatitis (SASSAD)verity score.43The scales are primarily ud in clinical trials and rarely in clinical practice,as they were generally not designed for this purpo.
Scale development in many cas included rigorous testing and evaluation of the follow-ing statistical properties:inter-and intrarater reliability,validity(ie,construct,content,and concurrent),internal consistency reliability,respon-siveness to change,and minimal clinically important difference.44,45The available literature suggests that the SCORAD index,the EASI score,and the Patient-Oriented Eczema Measure(POEM)verity scale have been adequately tested
and validated; therefore,their u can be considered when practical.44Of note,the EASI us objective physician estimates of dia extent and verity, while SCORAD incorporates both objective physician estimates of extent and verity and sub-jective patient asssment of itch and sleep loss.50 POEM was specifically designed to measure verity from the patient perspective and us7questions regarding symptoms and their frequency.43The Three Item Severity Scale(TISS)is another simplified scale that shows promi for future u in clinical practice,but it needs additional testing.44,54 Recognizing the lack of uniformity in dia-verity scale u,international efforts are underway to standardize measured outcomes.57This includes development of a core t of valid measures of signs and symptoms that can be feasibly recorded in controlled trials,which is directed toward
Table II.Recommendation for the diagnosis of atopic dermatitis
Patients with presumed atopic dermatitis should have their diagnosis bad on the criteria summarized in Box1.On occasion,skin biopsy specimens or other tests (such as rum immunoglobulin E,potassium hydroxide preparation,patch testing,and/or genetic testing)may be helpful to rule out other or associated skin conditions.J A M A CAD D ERMATOL
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