最新特应性皮炎指南中的首选治疗

夏威夷威可洛亚——全球医学教育学会/皮肤病教育基金会主办的夏威夷皮肤病研讨会上公布的2014年最新美国皮肤病学会（AAD）特应性皮炎指南强烈建议使用局部钙调磷酸酶抑制剂作为减少皮质类固醇使用的局部制剂（topical corticosteroid-sparing agents），甚至在2岁以下儿童中也是如此，在2岁以下儿童中，这些药物的使用仍为标签外使用。

在这一循证AAD指南中，使用局部钙调磷酸酶抑制剂作为减少类固醇使用的局部制剂的建议类别为A类，证据水平为I。在该指南中，主动使用局部钙调磷酸酶抑制剂作为主动计划的短期间歇性维持治疗以预防疾病急性加重的建议也是A-I建议。指南指出，没有必要监测局部钙调磷酸酶抑制剂的血液浓度。

指南强调了主动与患者讨论局部钙调磷酸酶抑制剂黑框警告的重要性，并强调长期监测研究的期中分析未发现恶性肿瘤增加。

指南的局部治疗章节中详细描述了湿裹疗法，该疗法能够有效地快速降低急性加重期间的特应性皮炎严重程度。指南强烈反对使用局部抗组胺药。

指南以较多篇幅详细描述了修复皮肤屏障的重要性。洗浴被推荐作为治疗的一个重要组成部分，但在最佳洗浴频率或持续时间方面尚无良好证据。AAD指南编写工作组成员Wynnis Tom医生表示，在使结痂脱落的同时需要保湿皮肤，为了不使皮肤随着水分蒸发而变得干燥，需要注意洗浴的持续时间。即使每天洗浴1次，效果也较好，只要患者在洗浴后使用保湿剂。治疗和维持的关键在于自由使用保湿剂。

指南指出，虽然保湿剂是特应性皮炎治疗的关键，但尚无证据显示哪种保湿产品最佳。此外，也无令人信服的证据表明含神经酰胺或水脂的处方装置在临床上优于非处方保湿剂。

这一2014年特应性皮炎指南是首份辟出一个完整章节专门讨论皮肤病诊断的AAD指南（J. Am. Acad. Dermatol. 2014;70:338-51）。这被认为很有必要，因为特应性皮炎的误诊是个问题，特别是在成人中。

指南强调，特应性皮炎的临床诊断需排除以下疾病，包括接触性皮炎、皮肤T细胞淋巴瘤、银屑病、光敏性反应、脂溢性皮炎和免疫缺陷疾病。目前，尚没有特异性生物标志物被建议用于诊断特应性皮炎或评估其严重程度。指南不建议采取监测免疫球蛋白E水平的流行做法。

该综合指南还包括一个有关光疗和全身性药物的章节。此外，一个有关预防疾病急性加重和使用辅助治疗的章节预计将在6月发表。

Tom医生声明是安进和Anacor公司所资助研究的无薪酬研究者。SDEF和本新闻机构率属于同一家母公司。

Atopic dermatitis update taps top therapy choices

By: BRUCE JANCIN, Internal Medicine News

WAIKOLOA, HAWAII – The 2014 update of the American Academy of Dermatology guidelines on atopic dermatitis take a strong stance in favor of the use of topical calcineurin inhibitors as topical corticosteroid-sparing agents, even in children less than 2 years old, where the use of the medications remains off-label.

The evidence-based AAD guidelines bestow a Class A, Level of Evidence I recommendation for the use of topical calcineurin inhibitors as topical steroid-sparing agents. The proactive use of topical calcineurin inhibitors as proactively scheduled, short-term, intermittent maintenance therapy to prevent disease flares also gets an A-I recommendation in the guidelines. The report states that there is no need to monitor blood levels of topical calcineurin inhibitors, Dr. Wynnis Tom noted at the Hawaii Dermatology Seminar, sponsored by the Global Academy for Medical Education/Skin Disease Education Foundation.

The section of the guidelines devoted to topical therapies includes a detailed description of wet wrap therapy, which is useful for quickly reducing atopic dermatitis severity during flares. The use of topical antihistamines gets a strong thumbs-down in the guidelines.The guidelines emphasize the importance of having a proactive discussion with the patient and/or parents about the black box warning for topical calcineurin inhibitors, stressing the fact that interim analyses of long-term surveillance studies do not show an increase in malignancies, said Dr. Tom, a member of the working group that developed the AAD guidelines and a pediatric dermatologist at the University of California, San Diego.

The guidelines go into considerable detail about the importance of fixing the skin barrier. Bathing is recommended as an important component of therapy, with the caveat that there is no good evidence as to the optimal frequency or duration.

"You want to get the crusting off and hydrate the skin; but you do have to be careful of how long the bath lasts, because you don’t want the skin to dry out as the water evaporates," Dr. Tom said. "I find bathing even daily is good, so long as people are using moisturizers afterward. That’s the key part both for treatment and maintenance: liberal use of moisturizers."

The guideline panel determined that while moisturizers are a cornerstone of atopic dermatitis therapy, no one moisturizer product has been shown to be better than the others. And that includes the prescription devices containing ceramides or hydrolipids, which haven’t persuasively been shown to have clinical advantages over inexpensive over-the-counter moisturizers.

The 2014 atopic dermatitis guidelines are the first-ever AAD guidelines to include an entire section devoted to the diagnosis of a dermatologic disorder (J. Am. Acad. Dermatol. 2014;70:338-51). This was deemed necessary because misdiagnosis of atopic dermatitis is a problem, particularly in adults.

The guidelines stress that atopic dermatitis is a clinical diagnosis that requires ruling out conditions including contact dermatitis, cutaneous T-cell lymphoma, psoriasis, photosensitivity reactions, seborrheic dermatitis, and immune deficiency diseases. At this time, no specific biomarkers can be recommended for the diagnosis of atopic dermatitis or assessment of its severity. In particular, according to the guidelines, the popular practice of monitoring immunoglobulin E levels isn’t recommended.

The comprehensive guidelines also include a section on phototherapy and systemic agents. In addition, a section on preventing disease flares and the use of adjunctive therapies is slated for release in June.

Dr. Tom reported serving as a financially uncompensated investigator for studies sponsored by Amgen and Anacor. SDEF and this news organization are owned by the same parent company.