Clinical Management of Atopic Dermatitis in Adults: Mapping of Expert Opinion in 4 Nordic Countries using a Modified Delphi Process

Abstract

Atopic dermatitis is a disease associated with various skin complaints. There is currently no consensus on the diagnosis and treatment of atopic dermatitis in the Nordic region. We therefore gathered 15 Nordic dermatologists to discuss patient education, diagnosis and treatment of atopic dermatitis. Patient education was identified as essential for effective management of atopic dermatitis, and treatment with moderate-to-potent topical glucocorticosteroids and emollients, followed by systemic treatment, was recommended. This article provides insights into the challenges associated with effective management of atopic dermatitis across the Nordic region and provides recommendations for optimal patient care. Similarities and differences in the everyday clinical management of moderate-to-severe atopic dermatitis in Nordic countries are unknown. Using a modified Delphi approach, 15 dermatologists from Denmark, Finland, Norway and Sweden completed face-to-face and online questionnaires and participated in summary discussions to map expert opinion on the clinical management of moderate-to-severe atopic dermatitis in these Nordic countries. Through discussions, 6 adult patient profiles, reflecting common disease presentations of atopic dermatitis, were identified. Using these case profiles, diagnostic work-up, treatment goals, patient education and treatment approaches were discussed. Patient education was identified as essential for effective management. A treatment sequence of moderateto-potent topical glucocorticosteroids and emollients, followed by systemic treatment, was recommended, allowing 3 months to ascertain systemic treatment response before switching, if necessary. Consensus was not reached on systemic treatment choice, reflecting differences in clinical practice and reimbursement between countries. Practical, case-based clinical recommendations were developed for optimal patient care.

Treatment Guidelines for Atopic Dermatitis Since the Approval of Dupilumab: A Systematic Review and Quality Appraisal Using AGREE-II

“…Calzavara et al ( 34 ), Smith et al ( 38 ), and Wollenberg et al ( 40 ) had their guidelines externally reviewed. Thyssen et al ( 39 ) was the only guideline to adequately describe systematic methods and criteria used to select evidence.…”

“…Implementation strategies that included tools or recommendations on how to carry out the guidelines in practice were missing. Only Ariens et al ( 18 ) and Thyssen et al ( 39 ) acknowledged the cost/resource implications of their recommendations.…”

“…In this systematic review of international CPGs for adult AD since the approval of dupilumab, we applied the validated AGREE-II instrument to measure and compare methodological quality before addressing recommendations for the use of this targeted on-label therapeutic. We found 12 relevant publications for supporting clinical decisions in the adult AD population; however, according to the validated AGREE-II instrument and a preset 70% threshold for item completion, only three CPGs were recommendable without modifications (38)(39)(40). Interestingly, recommendations regarding dupilumab initiation relative to conventional systemic therapy (CST) were highly variable, demonstrating a lack of consensus.…”

“…The most widely adopted guidelines for AD management were published by the American Academy of Dermatology in 2014; however, these predate the approval of dupilumab, leaving a gap of evidence-based, practical recommendations for up-todate management of adult AD (8,9). A number of recent clinical practice guidelines (CPGs) and recommendations from various groups were developed internationally to incorporate dupilumab in treatment algorithms (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42). To the best of our knowledge, the quality of these CPGs' methods and development processes…”

Atopic Dermatitis and Food Allergy: A Complex Interplay What We Know and What We Would Like to Learn

“…Recently, Nordic AD experts classified adult moderate-to-severe AD into six distinct patient profiles reflecting the spectrum of AD adult phenotypes. In this six-cluster phenotypic classification, cluster 2 included moderate to severe AD patients with type I allergies with increased prevalence of food allergies from childhood, allergic asthma, rhinoconjuctivitis, and family history of atopic diseases, indicating that specific AD phenotypes are highly associated with food allergy [ 28 ].…”