Atopic dermatitis: Recommendations for the prevention of flares

  • Continued use of either topical corticosteroids (1-2 times/wk) or topical calcineurin inhibitors (2-3 times/wk) after disease stabilization, to previously involved skin, is recommended to reduce subsequent flares or relapses.

Level of Evidence: I  Strength of Recommendation: A 


Read more about these recommendations 

AD is characterized by periods of acute worsening (‘‘flares’’) alternating with periods of relative quiescence after treatment. The precise definition of a flare, however, differs across studies and is an ongoing area of research.8 For pragmatic reasons, the definitions of flare from each published paper have been accepted for this guideline.

The strategy required to minimize recurrence varies depending on the individual and his or her frequency, severity, and sites of disease. Moisturizers should be an integral part of the maintenance treatment plan given their low risk and ability to improve skin hydration; some may also address the negative effects of epidermal barrier dysfunction.9-11 Two studies have shown that daily moisturizer use can lengthen the time to first flare, compared to no treatment.12-13 In some cases, this strategy may be adequate and anti-inflammatory therapies reinstituted only when new eczematous lesions are noted.13-15 This is considered a reactive approach to long-term management.

However, some individuals benefit from a more proactive method, whereby topical corticosteroids (TCS) or topical calcineurin inhibitors (TCI) are applied to both previously and newly involved skin on a scheduled, intermittent basis, and moisturizers used on all areas. Five randomized controlled trials (RCTs) with up to 4 weeks of acute disease control followed by twice weekly application of a midpotency TCS (fluticasone propionate or methylprednisolone aceponate) for 16 to 20 weeks demonstrated a reduction in the risk of flare development and lengthening of the time to relapse or first flare, relative to vehicle.14,16-19 A metaanalysis of the fluticasone studies found a substantial magnitude of benefit (pooled relative risk of flares of 0.46 [95% confidence interval {CI}, 0.38-0.55] vs vehicle).20 Two to 3 times weekly application of topical tacrolimus (0.03% in children, 0.1% in adults) to previously affected sites revealed similar benefits over 40 to 52 weeks of use (3 RCTs, pooled relative risk of flares of 0.78 [95% CI, 0.60-1.00]).20-23 This method of TCI use also led to a decrease in the number of flares and an increase in days free of topical anti-inflammatory use compared to vehicle. Further supporting proactive treatment are histologic findings of a persistently abnormal epidermal barrier and residual low-grade inflammation at previously involved sites, even when there is little clinical evidence of involvement.24

Navigate section 4 of the AD guideline: Disease flares and adjunctive therapy 

Citation note

When referencing this guideline in a publication, please use the following citation: Sidbury R, Tom WL, Bergman JN, Cooper KD, Silverman RA, Berger TG, et al. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;71(6):1218-33.

 


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