过敏性皮炎的管理最新实践指标.docx
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过敏性皮炎的管理最新实践指标.docx
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过敏性皮炎的管理最新实践指标
Diseasemanagementofatopicdermatitis:
anupdatedpracticeparameter
过敏性皮炎的管理:
最新实践指标
DonaldY.M.Leung,MD*;RichardA.Nicklas,MD;JamesT.Li,MD;I.LeonardBernstein,MD§;
JoannBlessing-Moore,MD;MarkBoguniewicz,MD_;JeanA.Chapman,MD**;
DavidA.Khan,MD;DavidLang,MD;RufusE.Lee,MD§§;JayM.Portnoy,MD;
DianeE.Schuller,MD__;SheldonL.Spector,MD***;andStephenA.Tilles,MD
ANNALSOFALLERGY,ASTHMA&IMMUNOLOGYVOLUME93,SEPTEMBER,2004
TABLEOFCONTENTS
I.
Preface...................................................................................................
S1
II.
ExecutiveSummary..........................................................................................
S3
III.
AnnotationstoFigure1...................................................................................
S6
IV.
SummaryStatements........................................................................................
S9
V.
Definitions...............................................................................................
S13
VI.
Immunopathology...........................................................................................
S13
VII.
ClinicalDiagnosis........................................................................................
S14
VIII.
First-lineManagementandTreatment.......................................................................
S15
IX.
IdentificationandEliminationofTriggeringFactors......................................................
S21
X.
Microbes..................................................................................................
S23
XI.
EmotionalStress..........................................................................................
S24
XII.
PatientEducation.........................................................................................
S25
XIII.
TreatmentoftheDifficult-to-ManagePatient...............................................................
S25
XIV.
Acknowledgments...........................................................................................
S28
XV.
References................................................................................................
S30
PREFACE
Atopicdermatitisisanimportantcomponentoftheatopicdiathesis.Itnotonlyfrequentlyaccompaniesallergicrespiratorydiseasebutoftenisthefirstmanifestationofallergicdisease.Mostpatientswithatopicdermatitiswilldevelopallergicrhinitisorasthma.Theevaluationandmanagementofatopicdermatitisare,therefore,anintegralpartofanallergist/immunologist’strainingandpractice.Itisalsoimportantfortheprimarycarephysiciantounderstandthebasisforeffectiveevaluationandmanagementofpatientswiththiscondition,sinceatopicdermatitisaffectsmorethan10%ofchildrenandcanhaveasignificantimpactonthepatient’squalityoflife.Asdiscussedinthisdocument,itisalsoimportantfortheprimarycarephysiciantoknowwhentoappropriatelyconsultaspecialistinatopicdermatitis.
SincetheinitialParameteronAtopicDermatitiswaspublishedin1997,therehavebeenremarkableadvancesintheunderstandingofthepathophysiologyofatopicdermatitis.1Thepathogenesisofatopicdermatitisinvolvesacomplexinflammatoryprocess,ourunderstandingofwhichisconstantlyundergoingrevision,asmoredatabecomeavailableontheroleofIgE-bearingLangerhanscells,atopickeratinocytes,monocytes/macrophages,eosinophils,andmastcellsandtheirinteractionwithinterleukin4(IL-4),IL-5,andIL-13producingTH2lymphocytes.Thereisacomplicatedinteractionbetweenthesecellsandtheirproductsandsusceptibilitygenesandthehostenvironment,whichleadstotheclinicalfindingsthatcharacterizeatopicdermatitis.Themajorobjectiveoftheparameter,DiseaseManagementofAtopicDermatitis:
AnUpdatedPracticeParameter,istoimprovethecareofpatientswithatopicdermatitis.Thisshouldbeaccomplishedbyestablishingboundariesfortheevaluationandmanagementofpatientswiththisconditionwhilereducingunwantedandunnecessaryvariationsintreatment.
ThisupdatedParameteronAtopicDermatitiswasdevelopedbytheJointTaskForceonPracticeParameters,whichhaspublished11practiceparametersforthefieldofallergyimmunology,includingtheoriginalParameteronAtopicDermatitis.The3nationalallergyandimmunologysocieties,theAmericanCollegeofAllergy,AsthmaandImmunology(ACAAI),theAmericanAcademyofAllergy,Asthma,andImmunology(AAAAI),andtheJointCouncilofAllergy,AsthmaandImmunology(JCAAI),havegiventheTaskForcetheresponsibilityforupdatingexistingparameters.ThisdocumentbuildsontheoriginalParameteronAtopicDermatitis.Itwaswrittenandreviewedbysubspecialistsinallergyandimmunologyandwasfundedbythe3allergyandimmunologyorganizationsnotedabove.
DonaldY.M.Leung,MD,PhD,whochairedtheworkgroupthatdevelopedtheoriginalParameteronAtopicDermatitis,preparedtheinitialdraftoftheupdatedparameteronthiscondition.TheJointTaskForcerevisedtheinitialdraftintoaworkingdraftofthedocument,whichincludedareviewofthemedicalliteratureusingavarietyofsearchenginessuchasPubMed.Publishedclinicalstudieswereratedbycategoryofevidenceandusedtoestablishthestrengthofaclinicalrecommendation(Table1).TheworkingdraftoftheupdatedParameteronAtopicDermatitiswasthenreviewedbyanumberofexpertsinallergyandimmunologyandspecificallybyexpertsonatopicdermatitis.Thisdocument,therefore,representsanevidence-based,broadlyacceptedconsensusopinion.
TheupdatedParameteronAtopicDermatitiscontainsanannotatedalgorithmthatpresentsthemajordecisionpointsfortheappropriateevaluationandmanagementofatopicdermatitis(Fig1).Alsoincludedinthisparameteraresummarystatements,whichrepresentthekeypointsintheevaluationandmanagementofatopicdermatitis.Thesesummarystatementsappearagainbeforeeachsectioninthisdocument,followedbytextthatsupportsthesummarystatement(s).TherearesectionsonDefinitions,Immunopathology,ClinicalDiagnosis,First-lineManagementandTreatment,IdentificationandEliminationofTriggeringFactors,Microbes,EmotionalStress,PatientEducation,andTreatmentoftheDifficult-to-ManagePatient.
Thereareanumberoflegitimatereasonsforthedevelopmentofpracticeparametersthataffecttheinteractionwithmanagedcareandhealthcareproviders;educationofmedicalstudents,interns,residents,andfellows;andtheestablishmentofboundariesandsupportforthepracticingphysician.Theprimaryreasonfordevelopingpracticeparameters,however,mustalwaysbetoimprovethequalityofcareforthepatient.Ifusedappropriately,thisupdatedParameteronDiseaseManagementofAtopicDermatitiswillbeanothersteptowardachievingthatgoal.
EXECUTIVESUMMARY
Atopicdermatitisisageneticallytransmitted,chronicinflammatoryskindiseasethataffects10%to20%ofchildrenand1%to3%ofadults.1Thevastmajorityofpatientsdevelopthediseasebeforetheageof5years,althoughitcanalsopresentinadulthood.2Atopicdermatitisisthefirstmanifestationofatopyinmanypatientswholaterdevelopallergicrhinitisand/orasthma,3apatternthathasbeenreferredtoepidemiologicallyas“theatopicmarch.”Pruritus,scratching,andchronicand/orrelapsingeczematouslesionsaremajorhallmarksofthedisease.Ininfantsandyoungchildren,thereisacharacteristicpatternofinvolvementoftheface,neck,andextensorskinsurfaces.Inolderchildrenandadults,theskinlesionsofteninvolvelichenificationandareusuallylocalizedtotheflexuralfoldsoftheextremities.Factorsthatmayexacerbatesymptomsinatopicdermatitispatientsincludetemperature,humidity,irritants,infections,food,inhalantandcontactallergens,andemotionalstress.4Foodallergyhasbeenimplicatedinapproximatelyonethirdofchildrenwithatopicdermatitis,althoughspecificIgEisoftenpresentwithoutclearrelevancetothediseaseprocess.5
Thepathogenesisofatopicdermatitisinvolvesacomplexinteractionbetweengeneticandenvironmentalfactors.Xerosis,scratching,andbothcolonization2,6–8andinfection9oftheskinbyStaphylococcusaureusallcontributetothediseaseprocess.Aswithallergicrhinitisandasthma,theinflammatoryreactioninatopicdermatitisinvolvesTH2lymphocyteactivation,resultingintheproductionofIL-4,IL-5,andIL-13.2OthercellsinvolvedinthisinflammationincludeIgE-bearingLangerhanscells,atopickeratinocytes,lymphocytes,monocytes/macrophages,eosinophils,andmastcells.10–12
Thediagnosisofatopicdermatitisisbasedonitsclinicalpresentationratherthandiagnostictesting.13However,thejudicioususeofpercutaneousskintestsorinvitrotestingforthepresenceofspecificIgEtorelevantallergensisasensitivewayofidentifyingpotentialallergictriggeringfactors.Double-blindfoodchallengesaresometimesnecessarytodeterminetherelevanceofspecificfoodingestiontosymptoms.14
Theeffectivemanagementofatopicdermatitisinvolvessomecombinationoftriggeravoidance,14–16measurestorestoreskinbarrierfunction,andanti-inflammatorymedication.4TriggeravoidanceshouldbeindividualizedbasedonacarefulhistoryandtheresultsofspecificIgEtesting.Barrierfunctioncanbeimprovedbycarefulhydrationandemollientapplication,suchassoakinginalukewarmbathfor20to30minutesfollowedbytheimmediateapplicationofanemollient.17
Therearemultipleanti-inflammatorymedicationoptionsavailablefortreatingatopicdermatitis.Topicalcorticosteroidsareappropriateforthe
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- 过敏性 皮炎 管理 最新 实践 指标