A team of expert dermatologists recently drafted recommendations for managing atopic dermatitis (AD) to optimize treatment outcomes. They noted that current treat-to-target recommendations for AD “may not include high enough treatment targets and do not fully consider patient needs.”
The team of 87 expert dermatologists from 44 countries developed the Aiming High in Eczema/Atopic Dermatitis (AHEAD) consensus-based recommendations utilizing insights from a global patient study alongside their own experience and expertise. The AHEAD recommendations, which were developed for patients of all ages and severities of AD aim to provide a framework for optimized management of the disease, taking into consideration disease severity, treatment goals and targets, as well as guidance for treatment escalation or modification.
The research notes that AD, the common and chronic inflammatory skin disease characterized by red, itchy, and painful skin can be associated with “significant long-term disease burden; physical symptoms can impair patients’ sleep quality, sexual relations, social interactions and work productivity, leading to mental health issues including anxiety and depression.”
Method
The expert initiative began with the formation of a seven-member executive steering committee (ESC). Recognizing the lack of evidence on patients’ treatment goals, needs, and expectations in AD, qualitative patient research was conducted in order to provide an evidence base for the creation of patient-focused recommendations.
Eligible patients had to be at least 18 years old, have a diagnosis of AD, and be currently receiving treatment for their condition. Patients were screened to ensure a wide range of ages, genders, educational levels, geographic locations, and AD severities were represented. Patients then took part in a 45-minute one-on-one telephone interview in their native language. They were asked about the impact of AD on their daily lives, the symptoms they felt were most significant, their views on current disease severity scoring systems, their treatment decision-making process, and their expectations for AD treatment.
Based on this patient research, experts were then invited to participate in a modified eDelphi voting process using a rating scale from 1 (strongly disagree) to 10 (strongly agree).
Results
A total of 88 patients from 15 countries participated in the study and reported that AD had a substantial impact on their lives. “Mental health issues such as anxiety and depression were commonly reported by patients with AD, and these symptoms had the largest impact on patients’ daily lives.” Furthermore, many of these patients reported that clinicians underestimated the burden of AD on their daily lives.
A total of 89% of invited experts took part in the voting process. All the AHEAD recommendations reached consensus, with all but one reaching a ‘strong’ consensus. This was the recommendation that related to patients choosing the AD features most important to them. Most of the experts involved agreed that a maximum of three AD features should be chosen in order to simplify the patient consultation process. However, some of the other experts felt that the number of features should not be limited and therefore no strong consensus was reached.
AHEAD Recommendations
Below is the list of 34 recommendations extracted from the study:
| Disease severity assessments and treatment goals and targets | |
| 1 | AD is a heterogeneous condition, and the outcome measures used to assess disease severity should be tailored to the patient’s reported signs and symptoms |
| 2 | Patient-reported outcomes are important tools for patients/caregivers to communicate the impact that AD has on their lives to others, especially to their physicians |
| 3 | Physician-reported outcomes are important tools for benchmarking the severity of the disease |
| 4 | The disease severity in a patient with AD should be assessed using both physician-reported and patient-reported outcomes |
| 5 | Physicians should discuss with the patient/caregiver the results of any outcome measures used and explain what the results mean in terms of disease severity and treatment choices |
| 6 | It is now possible to aim for higher targets to optimize patient outcomes whenever possible because more effective therapies are now available |
| 7 | The ultimate treatment goal in AD should be a satisfied patient with minimal impact on quality of life, clear/almost-clear skin with no/minimal itch |
| Long-term disease control | |
| 8 | Physicians should consider assessment of long-term disease control because disease activity on the day of the appointment may not reflect the patient’s overall condition over the previous weeks or months |
| 9 | Physicians and patients/caregivers should aim for long-term control of disease, with minimal flares and achievement of MDA, and physicians should consider the use of ADCT or RECAP for the assessment of disease control |
| The AHEAD approach: Combining treat-to-target principles with shared decision-making | |
| 10 | Patients/caregivers should be asked to choose 1–3 AD features that are most important to them (out of the following 6 features: itch, skin appearance/condition, sleep disturbance, mental health, skin pain and impact on daily life) |
| 11 | The physician should choose patient-reported outcome measures that reflect the patient’s/caregiver’s choice of AD features |
| 12 | The physician should also choose at least one objective clinical measure that gives an overall picture of the patient’s disease (EASI, SCORAD, or IGA and BSA) |
| 13 | The physician and patient/caregiver should discuss the chosen physician-reported and patient-reported outcomes and select either moderate or optimal targets; achievement of optimal targets is defined as MDA |
| 14 | Treatment response can be considered inadequate if the agreed targets are not met within 3–6 months; treatment modification or escalation should then be considered |
| 15 | Systemic therapy should be considered in patients with moderate-to-severe AD who have failed to achieve the agreed targets with topical medications or phototherapy, particularly if this is affecting their quality of life |
| 16 | Physicians and patients/caregivers should aim for optimal treatment targets to optimize disease control and patient outcomes when possible |
| Treatment targets for clinician-reported outcomes | |
| 17 | The moderate target for EASI should be EASI-75 or EASI ≤7, with EASI ≤7 only used in patients with moderate-to-severe AD |
| 18 | The optimal target for EASI should be EASI-90 or EASI ≤3 |
| 19 | The moderate target for SCORAD should be SCORAD-50 or SCORAD ≤24, with SCORAD ≤24 only used in patients with moderate-to-severe AD |
| 20 | The optimal target for SCORAD should be SCORAD-75 or SCORAD ≤10 |
| 21 | The moderate target for IGA and BSA should be IGA ≤2 and 50% improvement in BSA |
| 22 | The optimal target for IGA and BSA should be IGA 0/1 and BSA ≤2% |
| Treatment targets for patient-reported outcomes | |
| 23 | The moderate target for itch should be ≥4-point reduction in peak pruritus NRS |
| 24 | The optimal target for itch should be peak pruritus NRS ≤1 |
| 25 | The moderate target for skin appearance/condition should be ≥4-point reduction in POEM |
| 26 | The optimal target for skin appearance/condition should be POEM ≤2 |
| 27 | The moderate target for sleep disturbance should be ≥3-point reduction in sleep NRS |
| 28 | The optimal target for sleep disturbance should be sleep NRS ≤1 |
| 29 | The moderate target for mental health should be HADS-A <11 or HADS-D <11 |
| 30 | The optimal target for mental health should be HADS-A <8 and HADS-D <8 |
| 31 | The moderate target for skin pain should be ≥3-point reduction in pain NRS |
| 32 | The optimal target for skin pain should be pain NRS ≤1 |
| 33 | The moderate target for impact on daily life should be ≥4-point reduction in DLQI (patients >16 years of age), CDLQI (patients 4–16 years of age) or IDQOL (patients <4 years of age) |
| 34 | The optimal target for impact on daily life should be DLQI ≤1 (patients >16 years of age), CDLQI ≤1 (patients 4–16 years of age) or IDQOL ≤1 (patients <4 years of age) |
Conclusion
The consensus-based AHEAD recommendations merge treat-to-target principles with a shared decision-making approach, making it a novel strategy for optimizing AD care. This is a significant step forward in AD management, bringing with it greater personalization and improved patient outcomes. Authors note that “Future endeavors will involve the development of a tool to help implement the AHEAD recommendations in real-world clinical practice and studies to assess their feasibility and clinical value.”
Source:
- Silverberg, J. I., Gooderham, M., Katoh, N., Aoki, V., Pink, A. E., Binamer, Y., Rademaker, M., Fomina, D., Gutermuth, J., Ahn, J., Valenzuela, F., Ameen, M., Steinhoff, M., Kirchhof, M. G., Lio, P., & Wollenberg, A. (2024). Combining treat‐to‐target principles and shared decision‐making: International expert consensus‐based recommendations with a novel concept for minimal disease activity criteria in atopic dermatitis. Journal of the European Academy of Dermatology and Venereology. https://doi.org/10.1111/jdv.20229
