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===Atopic dermatitis===
===Atopic dermatitis===


* '''MIld - moderate atopic dermatitis''':
* '''MIld atopic dermatitis''':
** '''Initial treatment:'''
** Topical corticosteroids and emollients - mainstay therapy
*** '''Adult'''
*** '''Adult'''
**** Topical corticosteroids and emollients - mainstay therapy
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days  
***** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days  
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days  
***** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days  
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days  
***** Preferred regimen (3): [[drug name|fluticasone propionate 0.05% top.]] q12h-q24h for 14-28 days  
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
***** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
***** Alternative regimen (2): pimecrolimus 1% top. q8h
**** Alternative regimen (3) crisaborole 2% top.
***** Alternative regimen (3) crisaborole 2% top.
*** '''Pediatric'''
*** '''Pediatric'''
**** Topical corticosteroids and emollients - mainstay therapy
**** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days  
***** Preferred regimen (1): [[drug name|desonide 0.05%]] top. q12h-q24h for 14-28 days  
**** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days  
***** Preferred regimen (2): [[drug name|hydrocortisone 2.5% top.]] q12h-q24h for 14-28 days  
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.01% top.]] q12h-q24h for 14-28 days  
***** Preferred regimen (3): [[drug name|fluticasone propionate 0.05% top.]] q12h-q24h for 14-28 days  
**** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
***** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
***** Alternative regimen (2): pimecrolimus 1% top. q8h
**** Alternative regimen (3): crisaborole 2% top.
***** Alternative regimen (3) crisaborole 2% top.
* '''Moderate atopic dermatitis'''
****asSA
** Topical corticosteroids and emollients are the mainstay of therapy
****ASD
*** '''Adult'''
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
**** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
**** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14-28 days
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)   
**** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
**** Alternative regimen (1) tacrolimus 0.1% top. q8h ('''0.03% for adults who do not tolerate the higher dose)'''
** 1.2 '''Specific Organ system involved 2'''
**** Alternative regimen (2): pimecrolimus 1% top. q8h
*** 1.2.1 '''Adult'''
**** Alternative regimen (3) crisaborole 2% top.
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
** '''Pediatric'''
*** 1.2.2 '''Pediatric'''
*** Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
*** Preferred regimen (2): [[drug name|triamcinolone 0.1% top.]] q12h-q24h for 14 days
*** Preferred regimen (3): fluocinolone acetonide [[drug name|0.025% top.]] q12h-q24h for 14-28 days
*** Alternative regimen (1) tacrolimus 0.03%  top. q8h ('''Children (>2years)'''
*** Alternative regimen (2): pimecrolimus 1% top. q8h
*** Alternative regimen (3) crisaborole 2% top.
* '''Severe atopic dermatitis'''
** Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
*** '''Adult'''
**** Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3-5 mg/kg o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/u q month)'''  
**** Alternative regimen (1) methotrexatePO
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
*** '''Pediatric'''
**** Preferred regimen (1):
**** Preferred regimen (2): [[drug name|cyclosporine]] PO 3 to 5 mg/kg per day o.d. for 6 weeks ('''monitor BP and serum creatinine q2 weeks for three months, f/b q month)''' 
**** Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
**** Alternative regimen (2): azathioprine PO
**** Alternative regimen (3) mycophenolate mofetil PO
**** Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
* '''Severe refractory atopic dermatitis'''
** '''Adult'''
*** Preferred regimen (1): Intensive topical therapy
**** Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
**** Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A  two to three times per week
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. ('''C/I -''' '''abnormal renal function, uncontrolled hypertension or infection, and malignancy''')
*** Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
*** Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
*** Alternative regimen (5): azathioprine 2 to 3 mg/kg
*** Alternative regimen (6):  mycophenolate mofetil 1 to 2 g/day
*** Alternative regimen (7):  mycophenolic acid 720 to 1440 mg/day
*** Alternative regimen (8)  dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
** '''Pediatric'''
*** Preferred regimen (1): Intensive topical therapy
**** Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
*** Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB)  3 times per week ('''older children > 6 years''')
*** Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months ('''monitor renal and hepatic function''')
*** Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.('''up to a maximum of 25 mg per week''')
*** Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month


* 2 '''Stage 2 - Name of stage'''
*  
** 2.1 '''Specific Organ system involved 1 '''
*
**: '''Note (1):'''
**
**: '''Note (2)''':
*****  
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '<nowiki/>'''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)
** 2.2  '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days 
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1):  [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days  (maximum,500 mg per dose)


==References==
==References==

Revision as of 16:27, 5 October 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

The mainstay of treatment for atopic dermatitis depends upon the severity of the disease and is treated with combination of conservative and medical therapy. The goals of treatment include elimination of aggravating factors, skin barrier function repair, maintaining skin hydration and pharmacologic treatment of skin inflammation.

Conservative Therapy

Elimination of exacerbating factors Maintaining skin hydration Controlling pruritus
  • Avoid trigger factors such as low humidity, overheating of skin
  • Treating stress and anxiety
  • Avoid exposure to solvents and detergents
  • Treat skin infections such as Staphylococcus aureus and herpes simplex
  • Emollients and moisturizers
    • Thick creams, ointments (eg, petroleum jelly) with low/zero water content
    • Immediately after 5-minute, lukewarm baths BID
  • Bathing practices
    • Warm soaking baths or showers using mild or soap-free cleansers
  • Preferred regimen:
    • Sedatives: diphenhydramine, hydroxyzine, and cyproheptadine
    • Nonsedatives: fexofenadine, cetirizine or loratadine
  • Alternative regimen:
    • Topical doxepin
    • Topical calcineurin inhibitors
      •  Pimecrolimus 1% cream or tacrolimus 0.03% to 0.1%
  • Conservative
    • Tepid baths
    • Wet dressings (wet wraps)
    • Moisturizers containing anti-pruritic ingredients such as phenol, menthol, and camphor

Medical Therapy

  • Pharmacologic medical therapies for atopic dermatitis can be classified according to the several severity scales( (i.e SCORAD index, the eczema area and severity index [EASI], and the patient-oriented eczema measure [POEM]) which includes characteristics of the rash, questions about itch, sleep, impact on daily activities, and persistence of disease.

Atopic dermatitis

  • MIld atopic dermatitis:
    • Topical corticosteroids and emollients - mainstay therapy
      • Adult
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
      • Pediatric
        • Preferred regimen (1): desonide 0.05% top. q12h-q24h for 14-28 days
        • Preferred regimen (2): hydrocortisone 2.5% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.01% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3): crisaborole 2% top.
  • Moderate atopic dermatitis
    • Topical corticosteroids and emollients are the mainstay of therapy
      • Adult
        • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14-28 days
        • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14-28 days
        • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
        • Alternative regimen (1) tacrolimus 0.1% top. q8h (0.03% for adults who do not tolerate the higher dose)
        • Alternative regimen (2): pimecrolimus 1% top. q8h
        • Alternative regimen (3) crisaborole 2% top.
    • Pediatric
      • Preferred regimen (1): fluocinolone0.025%. q12h-q24h for 14 days
      • Preferred regimen (2): triamcinolone 0.1% top. q12h-q24h for 14 days
      • Preferred regimen (3): fluocinolone acetonide 0.025% top. q12h-q24h for 14-28 days
      • Alternative regimen (1) tacrolimus 0.03% top. q8h (Children (>2years)
      • Alternative regimen (2): pimecrolimus 1% top. q8h
      • Alternative regimen (3) crisaborole 2% top.
  • Severe atopic dermatitis
    • Phototherapy or systemic immunosuppressant treatment is the mainstay of therapy
      • Adult
        • Preferred regimen (1): Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Preferred regimen (2): cyclosporine PO 3-5 mg/kg o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/u q month)
        • Alternative regimen (1) methotrexatePO
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
      • Pediatric
        • Preferred regimen (1):
        • Preferred regimen (2): cyclosporine PO 3 to 5 mg/kg per day o.d. for 6 weeks (monitor BP and serum creatinine q2 weeks for three months, f/b q month)
        • Alternative regimen (1) Phototherapy Ultraviolet light therapy (phototherapy) with PUVA (psoralens plus ultraviolet A radiation), 3 times a week
        • Alternative regimen (2): azathioprine PO
        • Alternative regimen (3) mycophenolate mofetil PO
        • Alternative regimen (3) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
  • Severe refractory atopic dermatitis
    • Adult
      • Preferred regimen (1): Intensive topical therapy
        • Soak and smear: Soak for 15 minutes in a tub of water. Apply desoximetasone 0.25% top. to the whole body, except the groin, axillae, and face
        • Wet wrap therapy: desoximetasone 0.25% top. then occluded with wet wraps q12h
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B or psoralen plus ultraviolet A two to three times per week
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. (C/I - abnormal renal function, uncontrolled hypertension or infection, and malignancy)
      • Alternative regimen (3): prednisone 40 to 60 mg o.d. for one week, then taper the dose over the following two to three week
      • Alternative regimen (4): methotrexate 7.5 to 25 mg single weekly dose with folic acid 1 mg o.d.
      • Alternative regimen (5): azathioprine 2 to 3 mg/kg
      • Alternative regimen (6): mycophenolate mofetil 1 to 2 g/day
      • Alternative regimen (7): mycophenolic acid 720 to 1440 mg/day
      • Alternative regimen (8) dupilumab 600 mg SQ once and then 300 mg SQ every 2 weeks thereafter
    • Pediatric
      • Preferred regimen (1): Intensive topical therapy
        • Wet wrap therapy: desoximetasone 0.05% top. then occluded with wet wraps q12h-q24h for 2 to 14 days
      • Alternative regimen (1) Phototherapy: narrowband ultraviolet B (UVB) 3 times per week (older children > 6 years)
      • Alternative regimen (2): cyclosporine PO 2.5 to 5 mg/kg o.d. for 2-4 months (monitor renal and hepatic function)
      • Alternative regimen (3): methotrexate 0.5 mg/kg PO single weekly dose with folic acid 1 mg o.d.(up to a maximum of 25 mg per week)
      • Alternative regimen (4): methylprednisolone 0.5 mg/kg o.d. for 1-2 weeks tapered over one month

References

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