1、过敏性皮炎的管理最新实践指标Disease management of atopic dermatitis：an updated practice parameter过敏性皮炎的管理：最新实践指标Donald Y. M. Leung, MD*; Richard A. Nicklas, MD; James T. Li, MD; I. Leonard Bernstein, MD;Joann Blessing-Moore, MD; Mark Boguniewicz, MD_; Jean A. Chapman, MD*;David A. Khan, MD; David Lang, MD; Rufus
2、E. Lee, MD; Jay M. Portnoy, MD;Diane E. Schuller, MD_; Sheldon L. Spector, MD*; and Stephen A. Tilles, MDANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY VOLUME 93, SEPTEMBER, 2004 TABLE OF CONTENTSI.Preface.S1II.ExecutiveSummary.S3III.Annotations to Figure 1.S6IV.Summary Statements.S9V.Definitions.S13VI.Immu
3、nopathology.S13VII.Clinical Diagnosis.S14VIII.First-line Management and Treatment.S15IX.Identification and Elimination of Triggering Factors.S21X.Microbes.S23XI.Emotional Stress.S24XII.Patient Education.S25XIII.Treatment of the Difficult-to-ManagePatient.S25XIV.Acknowledgments.S28XV.References.S30PR
4、EFACEAtopic dermatitis is an important component of the atopic diathesis. It not only frequently accompanies allergic respiratory disease but often is the first manifestation of allergic disease. Most patients with atopic dermatitis will develop allergic rhinitis or asthma. The evaluation and manage
5、ment of atopic dermatitis are, therefore, an integral part of an allergist/immunologists training and practice. It is also important for the primary care physician to understand the basis for effective evaluation and management of patients with this condition, since atopic dermatitis affects more th
6、an 10% of children and can have a significant impact on the patients quality of life. As discussed in this document, it is also important for the primary care physician to know when to appropriately consult a specialist in atopic dermatitis.Since the initial Parameter on Atopic Dermatitis was publis
7、hed in 1997, there have been remarkable advances in the understanding of the pathophysiology of atopic dermatitis.1 The pathogenesis of atopic dermatitis involves a complex inflammatory process, our understanding of which is constantly undergoing revision, as more data become available on the role o
8、f IgE-bearing Langerhans cells, atopic keratinocytes, monocytes/macrophages, eosinophils, and mast cells and their interaction with interleukin 4 (IL-4), IL-5, and IL-13 producing TH2 lymphocytes. There is a complicated interaction between these cells and their products and susceptibility genes and
9、the host environment, which leads to the clinical findings that characterize atopic dermatitis. The major objective of the parameter, Disease Managementof Atopic Dermatitis: An Updated Practice Parameter, is to improve the care of patients with atopic dermatitis. This should be accomplished by estab
10、lishing boundaries for the evaluation and management of patients with this condition while reducing unwanted and unnecessary variations in treatment.This updated Parameter on Atopic Dermatitis was developed by the Joint Task Force on Practice Parameters, which has published 11 practice parameters fo
11、r the field of allergy immunology, including the original Parameter on Atopic Dermatitis. The 3 national allergy and immunology societies, the American College of Allergy, Asthma and Immunology (ACAAI), the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the Joint Council of Allergy
12、, Asthma and Immunology (JCAAI), have given the Task Force the responsibility for updating existing parameters. This document builds on the original Parameter on Atopic Dermatitis. It was written and reviewed by subspecialists in allergy and immunology and was funded by the 3 allergy and immunology
13、organizations noted above.Donald Y. M. Leung, MD, PhD, who chaired the workgroup that developed the original Parameter on Atopic Dermatitis, prepared the initial draft of the updated parameter on this condition. The Joint Task Force revised the initial draft into a working draft of the document, whi
14、ch included a review of the medical literature using a variety of search engines such as PubMed. Published clinical studies were rated by category of evidence and used to establish the strength of a clinical recommendation (Table 1). The working draft of the updated Parameter on Atopic Dermatitis wa
15、s then reviewed by a number of experts in allergy and immunology and specifically by experts on atopic dermatitis. This document, therefore, represents an evidence-based, broadly accepted consensus opinion.The updated Parameter on Atopic Dermatitis contains an annotated algorithm that presents the m
16、ajor decision points for the appropriate evaluation and management of atopic dermatitis (Fig 1). Also included in this parameter are summary statements, which represent the key points in the evaluation and management of atopic dermatitis. These summary statements appear again before each section in
17、this document, followed by text that supports the summary statement(s). There are sections on Definitions, Immunopathology, Clinical Diagnosis, First-line Management and Treatment, Identification and Elimination of Triggering Factors, Microbes, Emotional Stress, Patient Education, and Treatment of t
18、he Difficult-to-Manage Patient.There are a number of legitimate reasons for the development of practice parameters that affect the interaction with managed care and health care providers; education of medical students, interns, residents, and fellows; and the establishment of boundaries and support
19、for the practicing physician. The primary reason for developing practice parameters, however, must always be to improve the quality of care for the patient. If used appropriately, this updated Parameter on Disease Management of Atopic Dermatitis will be another step toward achieving that goal.EXECUT
20、IVE SUMMARYAtopic dermatitis is a genetically transmitted, chronic inflammatory skin disease that affects 10% to 20% of children and 1% to 3% of adults.1 The vast majority of patients develop the disease before the age of 5 years, although it can also present in adulthood.2 Atopic dermatitis is the
21、first manifestation of atopy in many patients who later develop allergic rhinitis and/or asthma,3 a pattern that has been referred to epidemiologically as “the atopic march.” Pruritus, scratching, and chronic and/or relapsing eczematous lesions are major hallmarks of the disease. In infants and youn
22、g children, there is a characteristic pattern of involvement of the face, neck, and extensor skin surfaces. In older children and adults, the skin lesions often involve lichenification and are usually localized to the flexural folds of the extremities. Factors that may exacerbate symptoms in atopic
23、dermatitis patients include temperature, humidity, irritants, infections, food, inhalant and contact allergens, and emotional stress.4 Food allergy has been implicated in approximately one third of children with atopic dermatitis, although specific IgE is often present without clear relevance to the
24、 disease process.5The pathogenesis of atopic dermatitis involves a complex interaction between genetic and environmental factors. Xerosis, scratching, and both colonization2,68 and infection9 of the skin by Staphylococcus aureus all contribute to the disease process. As with allergic rhinitis and as
25、thma, the inflammatory reaction in atopic dermatitis involves TH2 lymphocyte activation, resulting in the production of IL-4, IL-5, and IL-13.2 Other cells involved in this inflammation include IgE-bearing Langerhans cells, atopic keratinocytes, lymphocytes, monocytes/macrophages, eosinophils, and m
26、ast cells.1012The diagnosis of atopic dermatitis is based on its clinical presentation rather than diagnostic testing.13 However, the judicious use of percutaneous skin tests or in vitro testing for the presence of specific IgE to relevant allergens is a sensitive way of identifying potential allerg
27、ic triggering factors. Double- blind food challenges are sometimes necessary to determine the relevance of specific food ingestion to symptoms.14The effective management of atopic dermatitis involves some combination of trigger avoidance,1416 measures to restore skin barrier function, and anti-infla
28、mmatory medication.4Trigger avoidance should be individualized based on a careful history and the results of specific IgE testing. Barrier function can be improved by careful hydration and emollient application, such as soaking in a lukewarm bath for 20 to 30 minutes followed by the immediate application of an emollient.17There are multiple anti-inflammatory medication options available for treating atopic dermatitis. Topical corticosteroids are appropriate for the
