Peter Lio, MD, reviews an updated model of clinical guidance in a rapidly changing healthcare environment.
Over the past few years, targeted treatments for atopic dermatitis (AD)—from novel topicals to JAK inhibitors to biologics—have been taking up more and more space in the medicine chest. As practitioners prepare for these drugs’ wider availability, many are looking for professional guidance on how to incorporate the new medications into their patients’ treatment plans.
The 2024 post-pandemic medical environment is a vastly different from 10 years ago—when the last version of these AD guidelines was released. Since then, in nearly every corner of medicine, the standard of care has evolved to include cultural considerations, quality of life issues, and even combatting misinformation on social media. Meanwhile, as eczema diagnoses continue to rise, and new research and treatments emerge, healthcare reimbursement models are increasingly evidence-based, making the need for clear, actionable recommendations based on systematic research review more critical than ever.
It’s into this rapidly changing environment that the American Academy of Allergy, Asthma and Immunology Joint Task Force has released its new evidence-based guidelines, “The Immunology Joint Task Force on Practice Parameters GRADE−and Institute of Medicine−based recommendations.” This multidisciplinary effort led by Derek Chu, MD, a clinical associate professor of dermatology at Stanford Medicine in Stanford, CA, is notably different from previous guidelines. In order to steer optimal AD management across its entire spectrum of severity, the creation of the new guidelines involved diverse experts and patient representation, striving for inclusivity and equity while minimizing conflicts of interest.
Employing systematic evidence reviews and GRADE methodology, the task force developed 25 evidence-based recommendations encompassing topical treatments, bleach baths, dietary strategies, allergen immunotherapy, and systemic treatments (such as biologics, immunosuppressants, and light therapy). The guidelines will also be accompanied by user-friendly patient handouts.
The 2023 AD Guidelines focus on five key therapeutic questions, encompassing new therapies like light therapy and systemics:
1. Among patients with AD, what topical treatments should be used to achieve optimal outcomes?
2. Should elimination diets (dietary avoidance strategies) be used for AD?
3. Should dilute bleach baths be used for AD?
4. Should allergen immunotherapy be used for AD?
5. Among patients with AD, what systemic treatments, including phototherapy (UV light therapy), should be used to achieve optimal outcomes?
Peter Lio, MD, a co-author on the Guidelines and a clinical assistant professor of dermatology & pediatrics at Northwestern University, shared some of his insights into the guidelines with Practical Dermatology®. Dr. Lio is also a member of the Practical Dermatology Editorial Board.
Peter Lio, MD: I think the single most important point is that there is a lot going on in atopic dermatitis. We now have better understanding and better treatments than even just two or three years ago. This has resulted in a big change in the “treat to target” goal. Where we used to be happy to just get someone better, we are now able to aim for getting people clear or almost clear—and really improving quality of life for most, if not all, patients. That is a big change.
Still, for folks focused on inflammatory skin disease, the amount of new information can be overwhelming. To help clinicians sort out all this information, we’ve tried to focus these guidelines on some key questions that help frame this approach for clinical care. The goal was to be practical and digestible. Instead of a lengthy review of everything that has happened in the past decade, we wanted to put things into perspective.
Structurally, I think the idea of proactive therapy is really key. It has been discussed in the literature and is used in other parts of the world regularly. However, in my opinion, it’s not widely discussed or practiced in the United States outside of more specialized practitioners who focus on AD. These guidelines really highlight the proactive approach and show the impressive body of evidence that supports thinking about treating AD in this manner.
The Immunology Joint Task Force on Practice Parameters GRADE−and Institute of Medicine−based recommendations includes easy-to-use visual references for practitioners that explain the panel’s strength and certainty of its recommendations.
Dr. Lio: Increasingly, we are trying to correct past oversights in medicine by more deeply incorporating the patient perspective. One of the hardest parts is that there is not one simple universal patient opinion. Patients are incredibly diverse with respect to their knowledge, conceptions, and level of medical literacy. Their experiences are both incredibly valuable but also extremely limiting.
For example, I have many patients who feel that topical steroids have been terrible for them, and they absolutely refuse them going forward. I completely respect that and work with them to avoid steroids, but it is difficult for such an opinion to inform a guideline document that potentially could inform the therapy of millions of patients. The hard part is honoring that experience while placing it into a larger picture of more general patient care.
In this case, we’ve worked hard to showcase the non-steroidal options and explain why reactive therapy is not ideal for patients who are having more frequent flare ups. Keeping the patients involved throughout the process and having a true dialogue is what allowed everything to come together nicely in the end. While it certainly will not please everyone, it is our hope that every decision feels thoughtful and considered.
Dr. Lio: One of the biggest challenges, to be sure! While clinicians must stay on top of the cutting edge, we have to be careful not to focus on the new and emerging therapies too much since they’re less tested and often less accessible to many. Fortunately, the quality and robustness of data tends to favor more established treatments, and that drives the main part of the document. The new guidelines frame things from a clinical perspective rather than just presenting the data in isolation.
One of the things I think demonstrates the challenges here is in the case of the topical JAK inhibitor. In the new guidelines we offer a conditional recommendation based on low-certainty evidence against adding topical ruxolitinib over continued usual care alone. In the guidelines, it was further noted that “most well-informed patients with mild AD would prefer to avoid the uncertain small increase in serious harms over the modest benefits of adding topical ruxolitinib compared with standard care, and in particular, when considering other treatments with higher certainty for safety.”
This is a difficult situation that doesn’t exactly reflect my own personal clinical approach, and it will be interesting to see how this may change over time. My sense is that with more evidence and more time to become comfortable with the topical JAK inhibitor class, the recommendation is likely to become more favorable.
Dr. Lio: For the oral JAK inhibitor class, I think that the risk-benefit profile is tricky to know for sure and I try to take some time to explain why there is a boxed warning for these medications and others in the same class. I explain that the box warning really initiated with a study of a different medication in this class (tofacitinib) for a different disease state (rheumatoid arthritis) and was looking particularly at a population of patients who were 50 years of age and older and had a cardiovascular risk factor. I explain that this is different from the drugs we are using to treat AD, in a different condition, and with a different patient population, so we’re not totally sure what this means for one of our patients.
That being said, I don’t want anyone to be surprised or blindsided by the boxed warnings, so I take some time to go over it and explain the risks as they are written. I focus particularly on the safety evidence seen with the JAK inhibitors approved for AD in the AD population. I like to refer to a wonderful paper by Christopher Bunick, MD, PhD, who is an associate professor of dermatology at Yale, that shows that the numbers are actually quite comparable to historic data in the United States for many of the most concerning side effects.1
The single most important thing in my opinion is patient selection. I try to never push a medication on a patient, but rather offer it as a possible approach. For many of the patients I see, they are in such distress from their eczema that it is a relatively easy decision. For others, we sometimes want to exhaust other approaches before using an oral JAK inhibitor, but I can say that in my experience this is a very effective class of medications and has helped some of my patients with the most severe and refractory eczema I have ever seen.
Dr. Lio: My hope is that it will serve as a thorough and thoughtful update on many of the best practices and lead to more opportunities for shared decision making with patients. The paper itself is a tour de force: it is highly readable and even patient friendly! I like the idea of using it a bit like a menu at a restaurant: no one is telling you what to order, but if you’re not sure, it is nice to see a list of things that have good evidence behind them (and ones that don’t to avoid!) so that the next steps can be discussed.
I like to highlight the things that are not recommended, such as oral/systemic corticosteroids. Many dermatologists I meet tell me that they still use them for atopic dermatitis, and it’s fascinating to hear the rationale behind recommending against them in the paper: “Although systemic corticosteroids may be both rapid acting and effective, the panel inferred that their transient benefit and risk for adverse events (including repeated or prolonged cycles of systemic corticosteroids) did not align with most patients’ values and preferences.”
It goes on to say: “The harms associated with repeated systemic corticosteroid use, including their association with obtaining them through the emergency department, urgent care centers, or urgent clinician visits, consume more resources.” I meet many patients who have this love-hate relationship with systemic corticosteroids: they help quickly, but then there is often a great price to pay in the medium and long term. I try to emphasize that we need to do more than a quick fix and that the goal of therapy is to prevent bad flare ups that have people seeking systemic steroids, and while this is not an easy path, it tends to resonate well.
–by Caroline Knorr
1 . Daniele, Stefano, and Christopher Bunick. “JAK Inhibitor Safety Compared to Traditional Systemic Immunosuppressive Therapies.” J Drug Derm. JDD vol. 2022;21(12):1298-1303. doi:10.36849/JDD.7187
Peter Lio, MD, reviews an updated model of clinical guidance in a rapidly changing healthcare environment.