RESUMEN
BACKGROUND: Guidance addressing atopic dermatitis (AD) management, last issued in 2012 by the American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force, requires updating as a result of new treatments and improved guideline and evidence synthesis methodology. OBJECTIVE: To produce evidence-based guidelines that support patients, clinicians, and other decision-makers in the optimal treatment of AD. METHODS: A multidisciplinary guideline panel consisting of patients and caregivers, AD experts (dermatology and allergy/immunology), primary care practitioners (family medicine, pediatrics, internal medicine), and allied health professionals (psychology, pharmacy, nursing) convened, prioritized equity, diversity, and inclusiveness, and implemented management strategies to minimize influence of conflicts of interest. The Evidence in Allergy Group supported guideline development by performing systematic evidence reviews, facilitating guideline processes, and holding focus groups with patient and family partners. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach informed rating the certainty of evidence and strength of recommendations. Evidence-to-decision frameworks, subjected to public comment, translated evidence to recommendations using trustworthy guideline principles. RESULTS: The panel agreed on 25 recommendations to gain and maintain control of AD for patients with mild, moderate, and severe AD. The eAppendix provides practical information and implementation considerations in 1-2 page patient-friendly handouts. CONCLUSION: These evidence-based recommendations address optimal use of (1) topical treatments (barrier moisturization devices, corticosteroids, calcineurin inhibitors, PDE4 inhibitors [crisaborole], topical JAK inhibitors, occlusive [wet wrap] therapy, adjunctive antimicrobials, application frequency, maintenance therapy), (2) dilute bleach baths, (3) dietary avoidance/elimination, (4) allergen immunotherapy, and (5) systemic treatments (biologics/monoclonal antibodies, small molecule immunosuppressants [cyclosporine, methotrexate, azathioprine, mycophenolate, JAK inhibitors], and systemic corticosteroids) and UV phototherapy (light therapy).
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Asma , Dermatitis Atópica , Eccema , Hipersensibilidad , Inhibidores de las Cinasas Janus , Niño , Humanos , Estados Unidos , Dermatitis Atópica/tratamiento farmacológico , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Corticoesteroides , InmunosupresoresRESUMEN
PURPOSE OF REVIEW: IgE- and non-IgE-mediated food allergies are increasing in prevalence in children and adults worldwide. A food allergy diagnosis can be associated with a sense of overwhelm and stress and commonly has a negative impact on quality of life. RECENT FINDINGS: While there is an increased recognition of the psychosocial effects of food allergy, the current research reflects the experience of mostly White, well-educated wealthier populations. Some studies have now explored the psychosocial impact among other populations; however, further study is needed. It is important that physicians and allied health professionals screen for the potentially negative psychosocial effects of food allergy and provide education to promote safety and self-efficacy at each visit; however, time may be a limiting factor. Numerous validated questionnaires are now available to help assess the psychosocial impact of food allergies. Allergy-friendly foods are typically more expensive, and thus, it is imperative that physicians screen for food insecurity as well. Educational resources should be offered regarding living well with food allergies at each visit. For patients and families experiencing anxiety or food allergy burden that is difficult to manage, referral to a mental health provider should be considered. Resources regarding programs to help accessing safe foods should also be available. Further research is needed among diverse populations focusing on interventions to best support patients and families with food allergy.
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Hipersensibilidad a los Alimentos , Calidad de Vida , Niño , Adulto , Humanos , Hipersensibilidad a los Alimentos/diagnóstico , Hipersensibilidad a los Alimentos/epidemiología , Hipersensibilidad a los Alimentos/terapia , Encuestas y Cuestionarios , PrevalenciaRESUMEN
BACKGROUND: Atopic dermatitis (AD, eczema) is driven by a combination of skin barrier defects, immune dysregulation, and extrinsic stimuli such as allergens, irritants, and microbes. The role of environmental allergens (aeroallergens) in triggering AD remains unclear. OBJECTIVE: We systematically synthesized evidence regarding the benefits and harms of allergen immunotherapy (AIT) for AD. METHODS: As part of the 2022 American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters AD Guideline update, we searched the MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Global Resource for Eczema Trials, and Web of Science databases from inception to December 2021 for randomized controlled trials comparing subcutaneous immunotherapy (SCIT), sublingual immunotherapy (SLIT), and/or no AIT (placebo or standard care) for guideline panel-defined patient-important outcomes: AD severity, itch, AD-related quality of life (QoL), flares, and adverse events. Raters independently screened, extracted data, and assessed risk of bias in duplicate. We synthesized intervention effects using frequentist and Bayesian random-effects models. The GRADE approach determined the quality of evidence. RESULTS: Twenty-three randomized controlled trials including 1957 adult and pediatric patients sensitized primarily to house dust mite showed that add-on SCIT and SLIT have similar relative and absolute effects and likely result in important improvements in AD severity, defined as a 50% reduction in SCORing Atopic Dermatitis (risk ratio [95% confidence interval] 1.53 [1.31-1.78]; 26% vs 40%, absolute difference 14%) and QoL, defined as an improvement in Dermatology Life Quality Index by 4 points or more (risk ratio [95% confidence interval] 1.44 [1.03-2.01]; 39% vs 56%, absolute difference 17%; both outcomes moderate certainty). Both routes of AIT increased adverse events (risk ratio [95% confidence interval] 1.61 [1.44-1.79]; 66% with SCIT vs 41% with placebo; 13% with SLIT vs 8% with placebo; high certainty). AIT's effect on sleep disturbance and eczema flares was very uncertain. Subgroup and sensitivity analyses were consistent with the main findings. CONCLUSIONS: SCIT and SLIT to aeroallergens, particularly house dust mite, can similarly and importantly improve AD severity and QoL. SCIT increases adverse effects more than SLIT. These findings support a multidisciplinary and shared decision-making approach to optimally managing AD.
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Asma , Dermatitis Atópica , Eccema , Hipersensibilidad , Inmunoterapia Sublingual , Adulto , Animales , Humanos , Niño , Dermatitis Atópica/tratamiento farmacológico , Calidad de Vida , Teorema de Bayes , Desensibilización Inmunológica/efectos adversos , Pyroglyphidae , Hipersensibilidad/etiología , Asma/tratamiento farmacológico , Alérgenos/uso terapéutico , Inmunoterapia Sublingual/efectos adversos , Dermatophagoides pteronyssinusRESUMEN
BACKGROUND: Atopic dermatitis (AD) is a common skin condition with multiple topical treatment options, but uncertain comparative effects. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD prescription topical treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, ICTRP, and GREAT databases to September 5, 2022, for randomized trials addressing AD topical treatments. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. We classified topical corticosteroids (TCS) using 7 groups-group 1 being most potent. This review is registered in the Open Science Framework (https://osf.io/q5m6s). RESULTS: The 219 included trials (43,123 patients) evaluated 68 interventions. With high-certainty evidence, pimecrolimus improved 6 of 7 outcomes-among the best for 2; high-dose tacrolimus (0.1%) improved 5-among the best for 2; low-dose tacrolimus (0.03%) improved 5-among the best for 1. With moderate- to high-certainty evidence, group 5 TCS improved 6-among the best for 3; group 4 TCS and delgocitinib improved 4-among the best for 2; ruxolitinib improved 4-among the best for 1; group 1 TCS improved 3-among the best for 2. These interventions did not increase harm. Crisaborole and difamilast were intermediately effective, but with uncertain harm. Topical antibiotics alone or in combination may be among the least effective. To maintain AD control, group 5 TCS were among the most effective, followed by tacrolimus and pimecrolimus. CONCLUSIONS: For individuals with AD, pimecrolimus, tacrolimus, and moderate-potency TCS are among the most effective in improving and maintaining multiple AD outcomes. Topical antibiotics may be among the least effective.
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Asma , Dermatitis Atópica , Fármacos Dermatológicos , Eccema , Humanos , Dermatitis Atópica/tratamiento farmacológico , Tacrolimus/uso terapéutico , Metaanálisis en Red , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Fármacos Dermatológicos/uso terapéutico , Asma/tratamiento farmacológico , Antibacterianos/uso terapéuticoRESUMEN
BACKGROUND: Atopic dermatitis (AD) is an inflammatory skin condition with multiple systemic treatments and uncertainty regarding their comparative impact on AD outcomes. OBJECTIVE: We sought to systematically synthesize the benefits and harms of AD systemic treatments. METHODS: For the 2023 American Academy of Allergy, Asthma & Immunology and American College of Allergy, Asthma, and Immunology Joint Task Force on Practice Parameters AD guidelines, we searched MEDLINE, EMBASE, CENTRAL, Web of Science, and GREAT databases from inception to November 29, 2022, for randomized trials addressing systemic treatments and phototherapy for AD. Paired reviewers independently screened records, extracted data, and assessed risk of bias. Random-effects network meta-analyses addressed AD severity, itch, sleep, AD-related quality of life, flares, and harms. The Grading of Recommendations Assessment, Development and Evaluation approach informed certainty of evidence ratings. This review is registered in the Open Science Framework (https://osf.io/e5sna). RESULTS: The 149 included trials (28,686 patients with moderate-to-severe AD) evaluated 75 interventions. With high-certainty evidence, high-dose upadacitinib was among the most effective for 5 of 6 patient-important outcomes; high-dose abrocitinib and low-dose upadacitinib were among the most effective for 2 outcomes. These Janus kinase inhibitors were among the most harmful in increasing adverse events. With high-certainty evidence, dupilumab, lebrikizumab, and tralokinumab were of intermediate effectiveness and among the safest, modestly increasing conjunctivitis. Low-dose baricitinib was among the least effective. Efficacy and safety of azathioprine, oral corticosteroids, cyclosporine, methotrexate, mycophenolate, phototherapy, and many novel agents are less certain. CONCLUSIONS: Among individuals with moderate-to-severe AD, high-certainty evidence demonstrates that high-dose upadacitinib is among the most effective in addressing multiple patient-important outcomes, but also is among the most harmful. High-dose abrocitinib and low-dose upadacitinib are effective, but also among the most harmful. Dupilumab, lebrikizumab, and tralokinumab are of intermediate effectiveness and have favorable safety.
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Asma , Dermatitis Atópica , Eccema , Humanos , Dermatitis Atópica/tratamiento farmacológico , Metaanálisis en Red , Calidad de Vida , Ensayos Clínicos Controlados Aleatorios como Asunto , Resultado del TratamientoRESUMEN
Atopic dermatitis (AD) is associated with high levels of psychosocial burden, often resulting in poor mental health outcomes. Despite this association, few studies have evaluated the efficacy of mental health interventions within this population. Utilization of multidisciplinary and peer-led support, in addition to equipping patients with psychological tools, may be beneficial in improving mental health outcomes. Future research is needed to determine which interventions and formats are desired by, effective in and accessible to patients and caregivers with AD.
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Dermatitis Atópica , Humanos , Dermatitis Atópica/epidemiología , Salud Mental , Cuidadores/psicología , Calidad de VidaRESUMEN
BACKGROUND: Bleach bathing is frequently recommended to treat atopic dermatitis (AD), but its efficacy and safety are uncertain. OBJECTIVE: To systematically synthesize randomized controlled trials (RCTs) addressing bleach baths for AD. METHODS: We searched MEDLINE, EMBASE, CENTRAL, and GREAT from inception to December 29, 2021, for RCTs assigning patients with AD to bleach vs no bleach baths. Paired reviewers independently and in duplicate screened records, extracted data, and assessed risk of bias (Cochrane version 2) and GRADE quality of evidence. We obtained unpublished data, harmonized individual patient data and did Frequentist and Bayesian random-effects meta-analyses. RESULTS: There were 10 RCTs that enrolled 307 participants (median of mean age 7.2 years, Eczema Area Severity Index baseline mean of means 27.57 [median SD, 10.74]) for a median of 6 weeks (range, 4-10). We confirmed that other trials registered globally were terminated. Bleach baths probably improve AD severity (22% vs 32% improved Eczema Area Severity Index by 50% [ratio of means 0.78, 95% credible interval 0.59-0.99]; moderate certainty) and may slightly reduce skin Staphylococcal aureus colonization (risk ratio, 0.89 [95% confidence interval, 0.73-1.09]; low certainty). Adverse events, mostly dry skin and irritation, along with itch, patient-reported disease severity, sleep quality, quality of life, and risk of AD flares were not clearly different between groups and of low to very low certainty. CONCLUSION: In patients with moderate-to-severe AD, bleach baths probably improve clinician-reported severity by a relative 22%. One in 10 will likely improve severity by 50%. Changes in other patient-important outcomes are uncertain. These findings support optimal eczema care and the need for additional large clinical trials. TRIAL REGISTRATION: PROSPERO Identifier: CRD42021238486.
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Antiinfecciosos , Dermatitis Atópica , Eccema , Antiinfecciosos/uso terapéutico , Baños , Niño , Dermatitis Atópica/tratamiento farmacológico , Eccema/tratamiento farmacológico , Humanos , Prurito/tratamiento farmacológico , Staphylococcus aureusRESUMEN
BACKGROUND/OBJECTIVES: Patient education is important to families' ability to manage and cope with pediatric atopic dermatitis (AD). We evaluated whether an educational handbook could improve AD symptoms, caregiver confidence in AD management skills, and AD-related quality of life. METHODS: Caregivers of children with AD ages 1 month to 16 years were randomly assigned to the intervention arm (handbook in addition to standard AD management) or the control arm (standard management alone). Caregivers completed self-report outcome questionnaires prior to a clinical visit for AD and at 3-month follow-up. RESULTS: 175 caregivers completed questionnaires at baseline and follow-up. AD symptoms measured by the Patient-Oriented Eczema Measure (POEM) improved in both the handbook and control arms. However, the decrease in the mean POEM score in the handbook arm (-4.4, 95% CI [-5.8, -3.0]) did not differ from that in the control arm (-3.4, 95% CI [-4.8, -2.03]; P = .343). Change in quality of life did not differ between study arms. Among caregivers attending a new patient visit for AD, mean confidence scores (measured from 0 to 100) increased more in the handbook arm (67 [95% CI {60, 74}] to 83 [95% CI {77, 88}]) relative to the control arm (74 [95% CI {65, 82}] to 75 [95% CI {67, 83}]; P = .012). The majority of caregivers rated the handbook as helpful in managing the child's AD. CONCLUSIONS: Despite an adequate sample size, the handbook did not improve AD symptoms more than standard management alone. The handbook improved confidence in management skills for families attending new patient visits for AD.
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Dermatitis Atópica , Eccema , Cuidadores , Niño , Dermatitis Atópica/terapia , Humanos , Educación del Paciente como Asunto , Calidad de VidaRESUMEN
BACKGROUND: Peanut oral immunotherapy is a promising approach to peanut allergy, but reactions are frequent, and some patients cannot be desensitized. The anti-IgE medication omalizumab (Xolair; Genentech, South San Francisco, Calif) might allow more rapid peanut updosing and decrease reactions. OBJECTIVE: We sought to evaluate whether omalizumab facilitated rapid peanut desensitization in highly allergic patients. METHODS: Thirty-seven subjects were randomized to omalizumab (n = 29) or placebo (n = 8). After 12 weeks of treatment, subjects underwent a rapid 1-day desensitization of up to 250 mg of peanut protein, followed by weekly increases up to 2000 mg. Omalizumab was then discontinued, and subjects continued on 2000 mg of peanut protein. Subjects underwent an open challenge to 4000 mg of peanut protein 12 weeks after stopping study drug. If tolerated, subjects continued on 4000 mg of peanut protein daily. RESULTS: The median peanut dose tolerated on the initial desensitization day was 250 mg for omalizumab-treated subjects versus 22.5 mg for placebo-treated subject. Subsequently, 23 (79%) of 29 subjects randomized to omalizumab tolerated 2000 mg of peanut protein 6 weeks after stopping omalizumab versus 1 (12%) of 8 receiving placebo (P < .01). Twenty-three subjects receiving omalizumab versus 1 subject receiving placebo passed the 4000-mg food challenge. Overall reaction rates were not significantly lower in omalizumab-treated versus placebo-treated subjects (odds ratio, 0.57; P = .15), although omalizumab-treated subjects were exposed to much higher peanut doses. CONCLUSION: Omalizumab allows subjects with peanut allergy to be rapidly desensitized over as little as 8 weeks of peanut oral immunotherapy. In the majority of subjects, this desensitization is sustained after omalizumab is discontinued. Additional studies will help clarify which patients would benefit most from this approach.
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Antialérgicos/uso terapéutico , Desensibilización Inmunológica , Omalizumab/uso terapéutico , Hipersensibilidad al Cacahuete/tratamiento farmacológico , Hipersensibilidad al Cacahuete/terapia , Adolescente , Adulto , Alérgenos/inmunología , Arachis/inmunología , Niño , Método Doble Ciego , Femenino , Humanos , Inmunoglobulina E/sangre , Masculino , Pruebas Cutáneas , Adulto JovenRESUMEN
Atopic dermatitis (AD) is a chronic skin condition affecting children and adults, with a significant negative impact on patient and caregiver quality of life (QOL). Although effective treatments for AD are available, outcomes are often limited by poor adherence to treatment plans. Effective patient and caregiver education about the disease and its management is a necessary and important component of AD care. Therapeutic patient education (TPE) is a patient-centered process that aims to transfer information and skills necessary to manage and cope with a disease from health care professionals to patients and caregivers. Shared decision making between the health care provider and the patient/caregiver is an integral component of the TPE process and recognizes the importance of both the medical provider's clinical expertise, as well as the patient/caregiver's preferences and experiences regarding their own medical condition and its treatment. TPE programs for patients with AD and their caregivers are typically provided by multidisciplinary teams and utilize a number of different methods and tools to facilitate the transfer of knowledge and skills through both individual care and group-based educational sessions. TPE has been demonstrated to improve outcomes such as AD disease severity, treatment adherence, QOL, and coping with itch. It is important to consider strategies to reduce barriers to cost-effective accessible AD education and treatment.
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Toma de Decisiones , Dermatitis Atópica/terapia , Accesibilidad a los Servicios de Salud , Educación del Paciente como Asunto , Atención Dirigida al Paciente , Cuidadores , Humanos , Calidad de Vida , Cumplimiento y Adherencia al TratamientoRESUMEN
Atopic dermatitis (AD) is a chronic inflammatory skin disease, with a remitting relapsing course. The central diagnostic features of AD include pruritus, xerosis, eczematous lesions with a characteristic morphology and distribution, and a personal or family history of atopic disease. Several clinical studies have emphasized the link between AD and other atopic disorders including asthma, allergic rhinitis, and food allergies. More recent studies indicate possible links between AD and other nonatopic disorders, including ADHD, sleep disturbance, and mental health disorders, suggesting an even more profound impact of this disease. Furthermore, the social, emotional, and personal impact of AD for patients and their caregivers is substantial. Understanding both the clinical characteristics and implications of AD is critical to lessening the psychosocial, clinical, and economic burden of this disease.
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Dermatitis Atópica/complicaciones , Dermatitis Atópica/diagnóstico , Comorbilidad , Costo de Enfermedad , Dermatitis Atópica/psicología , Diagnóstico Diferencial , HumanosRESUMEN
Atopic dermatitis (AD) is a complex condition that results from the dynamic interplay between genetic predisposition, skin barrier defects, environmental factors, and a dysfunctional immune system. As a result, AD can be complicated by irritant and allergic contact dermatitis and imbalances in the skin microbiome, which can subsequently exacerbate the severity and complicate the course of preexisting atopic disease. Itch is an important symptom of AD, as it plays a large role in the quality of life of patients and their families. Since AD is a chronic, inflammatory disease that recrudesces throughout life, many have utilized alternative and/or complementary therapies, as monotherapy or in conjunction with conventional therapies, as a form of management.
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Terapias Complementarias , Dermatitis Alérgica por Contacto/complicaciones , Dermatitis Atópica/complicaciones , Dermatitis Atópica/terapia , Hipersensibilidad a los Alimentos/complicaciones , Prurito/etiología , Enfermedades Cutáneas Infecciosas/complicaciones , Humanos , Microbiota , Prurito/terapia , Calidad de Vida , Piel/microbiologíaRESUMEN
Atopic dermatitis (AD) is the most common pediatric skin disease. AD has a significant effect on patient and family quality of life caused by intense pruritus, sleep disruption, dietary and nutritional concerns, and psychological stress associated with the disease and its management. Multidisciplinary approaches to AD care have been developed in appreciation of the complex interplay among biological, psychological, behavioral, and dietary factors that affect disease control and the wide range of knowledge, skills, and support that patients and families require to effectively manage and cope with this condition. Common components of multidisciplinary treatment approaches include medical evaluation and management by an AD specialist, education and nursing care, psychological and behavioral support, and nutritional assessment and guidance. Models of care include both clinical programs and structured educational groups provided as adjuncts to standard clinical care. Available evidence suggests beneficial effects of multidisciplinary interventions in improving disease severity and quality of life, particularly for patients with moderate-to-severe disease. Additional research is needed to identify the best candidates for the various multidisciplinary approaches and evaluate the cost-effectiveness of these programs.
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Dermatitis Atópica/diagnóstico , Dermatitis Atópica/terapia , Grupo de Atención al Paciente , Financiación del Capital , Análisis Costo-Beneficio , Atención a la Salud/métodos , Manejo de la Enfermedad , Reforma de la Atención de Salud , Personal de Salud , Humanos , Colaboración IntersectorialRESUMEN
BACKGROUND: Educational materials are needed to support parent management of and coping with childhood food allergy. OBJECTIVES: To evaluate whether a food allergy handbook can improve parental knowledge, confidence, and quality of life associated with the management of food allergy. METHODS: Participants included 153 parents of children diagnosed as having food allergy within the past 12 months who were recruited from hospital-based allergy clinics and food allergy organizations. Parents were randomly assigned to receive the food allergy handbook either after a baseline survey (handbook group) or at the conclusion of study participation (control group). Outcomes were assessed using online surveys at baseline, 2-week follow-up, and 2-month follow-up. RESULTS: Compared with parents in the control group, parents in the handbook group had significantly greater improvement in knowledge at the 2-week (mean difference, 2.92; 95% confidence interval [CI], 2.20-3.64; P < .001) and 2-month (mean difference, 2.46; 95% CI, 1.68-3.25; P < .001) follow-ups, significantly greater improvement in confidence at the 2-week (mean difference, 0.24; 95% CI, 0.09-0.39; P = .002) and 2-month (mean difference, 0.47; 95% CI, 0.30-0.63; P < .001) follow-ups, and significantly greater improvement in quality of life at the 2-month follow-up (mean difference, -0.48; 95% CI, -0.79 to -0.16; P = .004). Parents reported satisfaction with the content the handbook, with mean ratings of individual sections ranging from 2.7 to 3.2 on a 0- to 4-point scale and modal ratings of 3 (very useful). CONCLUSIONS: The food allergy handbook evaluated in this study is an effective parent resource to supplement physician management of food allergy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01914978.
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Hipersensibilidad a los Alimentos/epidemiología , Hipersensibilidad a los Alimentos/prevención & control , Educación del Paciente como Asunto , Materiales de Enseñanza , Alérgenos/inmunología , Estudios de Casos y Controles , Preescolar , Femenino , Estudios de Seguimiento , Conocimientos, Actitudes y Práctica en Salud , Humanos , Lactante , Masculino , Satisfacción del Paciente , Calidad de Vida , Encuestas y CuestionariosRESUMEN
BACKGROUND: Peanut allergy is a major public health problem that affects 1% of the population and has no effective therapy. OBJECTIVE: To examine the safety and efficacy of oral desensitization in peanut-allergic children in combination with a brief course of anti-IgE mAb (omalizumab [Xolair]). METHODS: We performed oral peanut desensitization in peanut-allergic children at high risk for developing significant peanut-induced allergic reactions. Omalizumab was administered before and during oral peanut desensitization. RESULTS: We enrolled 13 children (median age, 10 years), with a median peanut-specific IgE level of 229 kU(A)/L and a median total serum IgE level of 621 kU/L, who failed an initial double-blind placebo-controlled food challenge at peanut flour doses of 100 mg or less. After pretreatment with omalizumab, all 13 subjects tolerated the initial 11 desensitization doses given on the first day, including the maximum dose of 500 mg peanut flour (cumulative dose, 992 mg, equivalent to >2 peanuts), requiring minimal or no rescue therapy. Twelve subjects then reached the maximum maintenance dose of 4000 mg peanut flour per day in a median time of 8 weeks, at which point omalizumab was discontinued. All 12 subjects continued on 4000 mg peanut flour per day and subsequently tolerated a challenge with 8000 mg peanut flour (equivalent to about 20 peanuts), or 160 to 400 times the dose tolerated before desensitization. During the study, 6 of the 13 subjects experienced mild or no allergic reactions, 5 subjects had grade 2 reactions, and 2 subjects had grade 3 reactions, all of which responded rapidly to treatment. CONCLUSIONS: Among children with high-risk peanut allergy, treatment with omalizumab may facilitate rapid oral desensitization and qualitatively improve the desensitization process.
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Alérgenos/uso terapéutico , Antialérgicos/administración & dosificación , Anticuerpos Antiidiotipos/administración & dosificación , Anticuerpos Monoclonales Humanizados/administración & dosificación , Desensibilización Inmunológica/métodos , Hipersensibilidad al Cacahuete/terapia , Administración Oral , Adolescente , Adulto , Alérgenos/inmunología , Antialérgicos/efectos adversos , Anticuerpos Antiidiotipos/efectos adversos , Anticuerpos Monoclonales Humanizados/efectos adversos , Arachis/inmunología , Quimioterapia Adyuvante , Niño , Femenino , Humanos , Masculino , Omalizumab , Hipersensibilidad al Cacahuete/inmunología , Proyectos Piloto , Grupos de Población , Riesgo , Resultado del Tratamiento , Adulto JovenRESUMEN
This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Atopic dermatitis: a practice parameter update 2012." This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma & Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. Published practice parameters of the Joint Task Force on Practice Parameters for Allergy & Immunology are available online at http://www.jcaai.org.
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Dermatitis Atópica/diagnóstico , Dermatitis Atópica/terapia , Manejo de la Enfermedad , Personal de Salud , Humanos , Atención al PacienteRESUMEN
Importance: Patient values and preferences can inform atopic dermatitis (AD) care. Systematic summaries of evidence addressing patient values and preferences have not previously been available. Objective: To inform American Academy of Allergy, Asthma & Immunology (AAAAI)/American College of Allergy, Asthma and Immunology (ACAAI) Joint Task Force on Practice Parameters AD guideline development, patient and caregiver values and preferences in the management of AD were systematically synthesized. Evidence Review: Paired reviewers independently screened MEDLINE, Embase, PsycINFO, and CINAHL databases from inception until March 20, 2022, for studies of patients with AD or their caregivers, eliciting values and preferences about treatment, rated risk of bias, and extracted data. Thematic and inductive content analysis to qualitatively synthesize the findings was used. Patients, caregivers, and clinical experts provided triangulation. The GRADE-CERQual (Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative Research) informed rating of the quality of evidence. Findings: A total of 7780 studies were identified, of which 62 proved eligible (n = 19â¯442; median age across studies [range], 15 years [3-44]; 59% female participants). High certainty evidence showed that patients and caregivers preferred to start with nonmedical treatments and to step up therapy with increasing AD severity. Moderate certainty evidence showed that adverse effects from treatment were a substantial concern. Low certainty evidence showed that patients and caregivers preferred odorless treatments that are not visible and have a minimal effect on daily life. Patients valued treatments capable of relieving itching and burning skin and preferred to apply topical corticosteroids sparingly. Patients valued a strong patient-clinician relationship. Some studies presented varied perspectives and 18 were at high risk for industry sponsorship bias. Conclusions and Relevance: In the first systematic review to address patient values and preferences in management of AD to our knowledge, 6 key themes that may inform optimal clinical care, practice guidelines, and future research have been identified.
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Asma , Dermatitis Atópica , Eccema , Humanos , Femenino , Adolescente , Masculino , Dermatitis Atópica/terapia , Cuidadores , Prurito , Eccema/tratamiento farmacológicoRESUMEN
BACKGROUND: Food allergy education is an ongoing process that must address unique safety concerns and psychosocial challenges at each developmental stage. Families require reliable information that is targeted to specific developmental stages to support the integration of food allergy management into daily life. OBJECTIVE: The purpose of this project was to develop age-specific, evidence-based patient education handouts with practical recommendations for managing and coping with food allergies at different developmental stages. METHODS: Handout content was based on: (1) practice guidelines for food allergy management; (2) literature addressing psychosocial and educational needs of patients with food allergy and their caregivers; and (3) clinical experience of the project team. Fifty-seven caregivers of patients (aged 0-21 years) with food allergy and 2 young adults with food allergy reviewed a draft of the handouts and completed an online survey to assess handout acceptability and usability and identify areas for improvement. Handouts were revised based on participant feedback. RESULTS: The majority of participants (79%) rated the amount of information in the age-specific handouts as "just right," versus "not enough" (9%) or "too much" information (12%). Sixty-three percent reported that they would be "very likely" to use the handouts as a resource and 35% "somewhat likely." Almost all participants (88%-100% by item) agreed that the handouts used elements of plain language writing and clear communication. CONCLUSION: Caregivers rated the age-based food allergy education handouts as understandable and useful. We anticipate that these handouts could be used during health care visits and directly accessed online by families.
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Cuidadores , Hipersensibilidad a los Alimentos , Alérgenos , Hipersensibilidad a los Alimentos/psicología , Hipersensibilidad a los Alimentos/terapia , Humanos , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND: The influence of diet on atopic dermatitis (AD) is complex, and the use of dietary elimination as a treatment has conflicting views. OBJECTIVE: To systematically review the benefits and harms of dietary elimination for the treatment of AD. METHODS: We searched MEDLINE, Embase, AMED, PsycINFO, and the Cochrane Central Register of Controlled Trials from inception to January 18, 2022, without language restrictions, for randomized controlled trials (RCTs) and observational studies comparing dietary elimination and no dietary elimination for the treatment of AD. We conducted random-effects meta-analyses of eczema outcomes. We used the grading of recommendations, assessment, development, and evaluation approach to assess certainty of evidence (CRD42021237953). RESULTS: Ten RCT (n = 599; baseline median of study mean age, 1.5 years; median of study mean SCOring Atopic Dermatitis index, 20.7, range, 3.5-37.6) were included in the meta-analysis. Compared with no dietary elimination, low-certainty evidence showed that dietary elimination may slightly improve eczema severity (50% with vs 41% without dietary elimination improved the SCOring Atopic Dermatitis index by a minimally important difference of 8.7 points, risk difference of 9% [95% CI, 0-17]), pruritus (daytime itch score [range, 0-3] mean difference, -0.21 [95% CI, -0.57 to 0.15]), and sleeplessness (sleeplessness score [range, 0-3] mean difference, -0.47 [95% CI, -0.80 to -0.13]). There were no credible subgroup differences based on elimination strategy (empiric vs guided by testing) or food-specific sensitization. Insufficient data addressed harms of elimination diets among included RCTs, although indirect evidence suggests that elimination diets may increase the risk for developing IgE-mediated food allergy. CONCLUSIONS: Dietary elimination may lead to a slight, potentially unimportant improvement in eczema severity, pruritus, and sleeplessness in patients with mild to moderate AD. This must be balanced against potential risks for indiscriminate elimination diets including developing IgE-mediated food allergy and withholding more effective treatment options for AD.
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Dermatitis Atópica , Eccema , Trastornos del Inicio y del Mantenimiento del Sueño , Dermatitis Atópica/epidemiología , Dermatitis Atópica/terapia , Dieta , Humanos , Inmunoglobulina E , Lactante , PruritoRESUMEN
Atopic dermatitis (AD) is one of the most common pediatric skin disorders. Because treatment involves allergen avoidance, dietary changes, and behavior modification, multidisciplinary treatment models have been used to complement conventional medication therapy. However, predictors of clinical response in these multidisciplinary models have not been studied. This study examined factors associated with a reduction in AD severity in a multidisciplinary outpatient pediatric AD treatment program providing medical, nutritional, and behavioral support. Data were collected from 170 patients between 2001 and 2006. The Eczema Area and Severity Index (EASI) score was determined at the time of each visit. Using a logistic regression model, we investigated the association of baseline demographic and clinical characteristics with clinical outcome. We also analyzed the association between improvement in the EASI score and behavioral changes. One hundred thirty-eight patients had significantly improved EASI scores, and 32 patients were nonresponders. Responders had a median improvement of 79% in their EASI score, whereas nonresponders had a 53% worsening of their EASI score (p < 0.0001) and a significantly worse absolute EASI score (p < 0.001). Predictors of clinical success included baseline EASI score, baseline age, and improved parental adherence to treatment recommendations. Improvement in the EASI score significantly correlated with quality-of-life measures: decreased itching and scratching, difficulty sleeping, and parental concerns about side effects. A multidisciplinary model of AD treatment has the best clinical outcomes in younger patients with severe AD. Ensuring parental compliance with treatment recommendations is important for clinical response.