Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis

Level of evidence grades (I-III) and strength of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Note from the National Guideline Clearinghouse (NGC): This document is the first section in a series of four and covers methods for diagnosis and assessment of atopic dermatitis (AD). The second guideline in the series will address the management and treatment of AD with pharmacologic and nonpharmacologic topical modalities; the third section will cover phototherapy and systemic treatment options; and the fourth section will address the minimization of disease flares, educational interventions, and use of adjunctive approaches.

Features to Be Considered in the Diagnosis of Patients with AD

Essential Features—Must be present: Pruritus Eczema (acute, subacute, chronic): Typical morphology and age-specific patterns* Chronic or relapsing history *Patterns Include: Facial, neck, and extensor involvement in infants and children Current or previous flexural lesions in any age group Sparing of the groin and axillary regions Important Features—Seen in most cases, adding support to the diagnosis: Early age of onset Atopy: Personal and/or family history Immunoglobulin E reactivity Xerosis Associated Features—These clinical associations help to suggest the diagnosis of AD but are too nonspecific to be used for defining or detecting AD for research and epidemiologic studies: Atypical vascular responses (e.g., facial pallor, white dermographism, delayed blanch response) Keratosis pilaris/pityriasis alba/hyperlinear palms/ichthyosis Ocular/periorbital changes Other regional findings (e.g., perioral changes/periauricular lesions) Perifollicular accentuation/lichenification/prurigo lesions Exclusionary Conditions—It should be noted that a diagnosis of AD depends on excluding conditions, such as: Scabies Seborrheic dermatitis Contact dermatitis (irritant or allergic) Ichthyoses Cutaneous T-cell lymphoma Psoriasis Photosensitivity dermatoses Immune deficiency diseases Erythroderma of other causes Adapted from Eichenfield LF, Hanifin JM, Luger TA, Stevens SR, Pride HB. Consensus conference on pediatric atopic dermatitis. J Am Acad Dermatol 2003;49:1088-95. Used with permission of the American Academy of Dermatology.

Recommendation for the Diagnosis of AD

Patients with presumed AD should have their diagnosis based on the criteria summarized in the box above. On occasion, skin biopsy specimens or other tests (such as serum immunoglobulin E, potassium hydroxide preparation, patch testing, and/or genetic testing) may be helpful to rule out other or associated skin conditions.

Strength of Recommendations for the Diagnosis and Assessment of AD

Recommendation	Strength of Recommendation	Level of Evidence	References
Diagnosis made using criteria in the box above	C	III	Mevorah et al., 1988; Gu et al., 2001; Lan et al., 2009; Diepgen, Sauerbrei, & Fartasch, 1996; De, Kanwar, & Handa, 2006; Loden, Andersson, & Lindberg, 1998; Samochocki & Dejewska, 2012; Samochocki, Paulochowska, & Zabielski, 2000; Chalmers et al., 2007; Firooz et al., 1999; Saeki et al., 2007; Firooz & Kashani, 2008; Hamada et al., 2005; Williams et al., 1994; Williams et al., 1996
No specific biomarkers for diagnosis or severity assessment	B	II	Murat-Susic et al., 2006; Schulte-Herbruggen et al., 2007; Amon et al., 2000; Dhar et al., 2005; Gerdes, Kurrat, & Mrowietz, 2009; Aral et al, 2006; Di Lorenzo et al., 2003; El Mongy et al., 2008; Ezzat, Hasan, & Shaheen, 2011; Jahnz-Rozyk et al., 2005; Nakazato et al., 2008; Belloni Fortina et al., 2006; Gutgesell et al., 2002; Hirai et al., 1996; Hon et al., 2007; Horikawa et al., 2002; Kakinuma et al., 2003; La Grutta et al., 2005; Leung et al., 2003; Mostafa et al., 2008; Oflazoglu et al., "CD30 expression," 2008; Oflazoglu et al., "CD40 expression," 2008; Ott et al., 2010; Raap et al., 2006; Song et al., 2006; Wolkerstorfer et al., 1998
Immunoglobulin E levels not routinely recommended	A	I	Schneider et al., 2013; Murat-Susic et al., 2006; Schulte-Herbruggen et al., 2007; Gerdes, Kurrat, & Mrowietz, 2009; Aral et al., 2006; Vakirlis et al., 2011; Wu et al., 2011
Available disease severity scales not for routine clinical use	C	II	Schmitt, Langan, & Williams, 2007; Schram et al., 2012; Sprikkelman et al., 1997; Angelova-Fischer et al., 2005; Wolkerstorfer et al., 1999; Linnet & Jemec, 1999; Hon et al., 2006; Barbier et al., 2004; Charman, Venn, & Williams, 2002; Charman, Venn, & Williams, 2004; Charman et al., 1999; Cosickic et al., 2010; Emerson, Charman, & Williams, 2000; Hanifin et al., 2001; Holm et al., 2007; Oranje et al., 1997; Rullo et al., 2008
Available quality of life severity scales not for routine clinical use	C	II	Chamlin et al., 2007; Augustin et al., 2004; Hon et al, 2006; Misery et al., 2007
Should query itch, sleep, impact on daily activity, and disease persistence	C	III	Chamlin et al., 2005; Hon et al., 2008; Dawn et al., 2009; Lewis-Jones, 2006; Weisshaar et al., 2008; Ricci et al., 2007; Bender et al., 2008; Ben-Gashir, Seed, & Hay, 2002
Awareness and discussion of common associations	C	I and II	Chamlin et al., 2005; Hon et al., 2008; Batlles-Garrido et al., 2010; Chawes et al., 2010; Sultesz et al., 2010; Kyllonen et al., 2006; Hwang et al., 2010; Hyvarinen et al., 2005; Eller et al., 2009; Horwitz, Hossain, & Yousef, 2009; Bashir, Dar, & Rao, 2010; Schmitt et al., "Psychiatric comorbidity," 2009; Schmitt et al., "Atopic eczema," 2009; Yaghmaie, Koudelka, & Simpson, 2013; Harding et al., 2008; Synnerstad et al., 2008; Vajdic et al., 2009; Kajbaf, Asar, & Alipoor, 2011; Vlaski et al., 2006
Integrated, multidisciplinary approach to care	C	III	Boguniewicz et al., 2008; Ricci et al., 2009

Recommendations for the Use of Biomarkers in the Assessment of AD

• For patients with presumed AD, there are no specific biomarkers that can be recommended for diagnosis and/or assessment of disease severity.
• Monitoring of immunoglobulin E levels is not recommended for the routine assessment of disease severity.

Recommendations for Disease Severity and Clinical Outcomes Assessment

• For the general management of patients with AD, available disease severity measurement scales are not recommended for routine clinical practice, because they were not usually designed for this purpose.
• For the general management of patients with AD, available patient quality of life measurement scales are not recommended for routine clinical practice.
• It is recommended that clinicians ask general questions about itch, sleep, impact on daily activity, and persistence of disease, and currently available scales be used mainly when practical.

Recommendations for the Assessment of Clinical Associations of AD

• Physicians should be aware of and assess for conditions associated with AD, such as rhinitis/rhinoconjunctivitis, asthma, food allergy, sleep disturbance, depression, and other neuropsychiatric conditions, and it is recommended that physicians discuss them with the patient as part of the treatment/management plan, when appropriate.
• An integrated, multidisciplinary approach to care may be valuable and is suggested for AD patients who present with common associations.

Definitions:

Levels of Evidence

1. Good-quality patient-oriented evidence (i.e., evidence measuring outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life)
2. Limited-quality patient-oriented evidence
3. Other evidence including consensus guidelines, opinion, case studies, or disease-oriented evidence (i.e., evidence measuring intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes)

Grades of Recommendation

1. Recommendation based on consistent and good quality patient-oriented evidence
2. Recommendation based on inconsistent or limited quality patient-oriented evidence
3. Recommendation based on consensus, opinion, case studies, or disease-oriented evidence