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152 Textbook of Diagnostic and Therapeutic Procedures in Allergy
Figure 7. NRS for Pruritus
10 – Worst imaginable itch
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In the past 7
days…
No
itch
0 1 2 3 4 5 6 7 8 9
Worst
imaginable
itch 10
how intense was
your itch at its
worst?
012345678
9
10
how intense was
your itch in
general?
0 – No itch
6 – Distracts from activities
8 – Wakes you up from sleep
Figure 7. NRS for pruritus.
by asking patients to report on average peak pruritus score over seven days compared to the general
average pruritus score (Figure 7).
Severity Scoring of Atopic Dermatitis (SCORAD)
The SCORAD index evaluates disease extent (percentage of the area involved) and five clinical
characteristics: erythema, edema/papulation, oozing/crusting, excoriation and lichenification.
Clinical characteristics are assessed based on an average representative area on a scale of 0 to 3,
with 0 indicating the absence of the characteristic and 3 indicating severe intensity. In addition to
health care practitioner scoring, SCORAD also incorporates patients’ subjective assessments of
pruritus and sleep loss (each assessed on a scale of 0–10) (Kunz et al. 1997; “Severity Scoring of
Atopic Dermatitis: The SCORAD Index. Consensus Report of the European Task Force on Atopic
Dermatitis” 1993). The final score is calculated with the following formula: extent/5 + intensity ×
7/2 + subjective items. This scoring tool has been widely used for many years and found to be valid
and reliable across many interobserver in many trials (Schmitt et al. 2013).
Eczema Area and Scoring Index (EASI)
EASI was developed as a severity scoring system by adapting the PASI (Psoriasis Area and
Severity Index) (Hanifin et al. 2001). This validated scoring tool evaluates AD severity based on
the extent of disease at four body sites and measures erythema, induration/papulation, excoriation
and lichenification on a scale of 0 to 3 with 3 indicating severe findings. No patient-reported
subjective outcomes are included. The final score is determined by adding up the total scores per
body region (determined from the sum of severity scores multiplied by the area score multiplied by
the corresponding body region constant weighted value). Scores greater than 21 are characterized as
severe diseases, while scores ranging from 50.1 to 72 are considered very severe diseases.
Investigators’ Global Assessment (IGA)
IGA is a scoring tool that can be used to measure overall disease severity on a scale of 0 (clear) to
5 (very severe disease) based on clinical characteristics of erythema, infiltration, papulation, oozing
and crusting as general guidelines. The simple scoring system of the IGA confers an advantage
over measures such as SCORAD or EASI, however, has a high variability among observers thus
less reproducible (Rehal and Armstrong 2011). Recently, a validated IGA (vIGA-AD) scale for
AD was published based on expert consensus with the goal of harmonizing efficacy and outcome
assessments in clinical trials for AD (see Table 4) (Simpson et al. 2020). The vIGA-AD is the only
Allergic Contact Dermatitis and Atopic Dermatitis 153
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Table 4. Validated IGA.
validated IGA scale that is feasible, simple and a good option for use in clinical practice. However,
the vIGA-AD does not include the extent of the disease (percentage of body surface area (BSA)
affected) and, as a result, fails to capture an important aspect of severity.
Patient-Oriented Eczema Measure (POEM)
The Patient-Oriented Eczema Measure (POEM) was first developed as a tool to monitor symptoms
of AD based on patient perspectives (Charman et al. 2004). It determines an overall score based on
patient responses to questions assessing the frequency of pruritus, disrupted sleep, the integrity of skin
and other characteristics of eczematous skin based on seven questions (Figure 8). Like the IGA, it is
relatively straightforward, able to be completed quickly and specifically targets symptoms important
to patients, thus it is a useful tool in clinical practice. However, in contrast with SCORAD, EASI and
the IGA, POEM is based on patient-reported symptoms only and does not utilize clinician input.
Atopic Dermatitis Control Tool (ADCT)
Atopic Dermatitis Control Tool (ADCT) is a recently validated, brief and easily scored patient
self-assessment tool (Pariser et al. 2020; Simpson et al. 2020). It consists of six concise questions
to evaluate the different dimensions of AD control identified as relevant by patients and clinicians
(Figure 9). ADCT can be self-administered by patients or used in routine consultations. It is designed
to help facilitate meaningful patient-physician discussion on the control of AD in every day clinical
practice, enabling improvements in disease monitoring.
Special Considerations
Evaluation of Pediatric Patients
Pediatric patients have unique characteristics to consider when treating AD in this population.
The distribution of AD lesions in infants and young children (zero to two years of age) may
predominantly involve extensor surfaces, cheeks or may be generalized with sparing of the diaper
area (Rudikoff and Lebwohl 1998). Pediatric patients also have a higher BSA-to-weight ratio and
thus have a higher risk of systemic absorption of topical corticosteroid therapy. Another important
consideration for infants and children with eczema, particularly severe and early onset disease,
154 Textbook of Diagnostic and Therapeutic Procedures in Allergy
Figure 8. POEM Questionnaire
Please circle one response for each of the seven questions below about
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your/your child’s eczema. If your child is old enough to understand the questions
then please fill in the questionnaire together. Please leave blank any questions
you feel unable to answer.
1. Over the last week, how many days has your/your child’s skin been itchy
because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
2. Over the last week, how many nights has your/your child’s sleep been
disturbed because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
3. Over the last week, how many days has your/your child’s skin been bleeding
because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
4. Over the last week, how many days has your/your child’s skin been weeping or
oozing clear fluid because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
5. Over the last week, how many days has your/your child’s skin been cracked
because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
6. Over the last week, how many days has your/your child’s skin been flaking off
because of eczema?
No days 1–2 days 3–4 days 5–6 days Every day
7. Over the last week, how many days has your/your child’s skin felt dry or rough
because of eczema?
No Days 1–2 Days 3–4 days 5–6 days Every day
TOTAL SCORE (Maximum 28): ______
Figure 8. POEM Questionnaire.
Allergic Contact Dermatitis and Atopic Dermatitis 155
INTERPRETING THE ADCT TOTAL SCORE:
atopic
conversation on sustained control in clinical practice.
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THE ADCT SCORE
1: Each ADCT question is scored 0–4 points, as shown in the table above
2: The sum of the scores from all six ADCT questions forms the ADCT total score
POINT-IN-TIME CONTROL STATUS
A higher score indicates lower AD control
A patient’s AD may not be well controlled if:
above
CHANGES IN CONTROL STATUS OVER TIME
A change of 5 points is the threshold for meaningful within-person change
atopic dermatitis control
dermatitis control
ADCT can be used to detect change over time supporting a patient-physician
is the increased risk for IgE-mediated food allergy. Studies have shown the development of food
allergy (FA) may occur via the exposure of potential allergens to the defective skin barrier in AD, a
process called transcutaneous sensitization (Lack et al. 2003). Based on the results of the Learning
Early About Peanut Allergy (LEAP) trial, infants with severe eczema are now recommended to
begin the early introduction of peanuts to decrease the likelihood of developing peanut allergy (Du
Toit et al. 2015). Given the increased risk of sensitization and FA in patients with severe AD, it is
generally recommended to test for peanut allergy prior to introducing it into the diet (Singh et al.
Figure 9. ADCT.
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2022). For patients with mild to moderate eczema, no specific food testing is required prior to the
introduction of foods. The role of testing for FA before the introduction is controversial, as some
studies have shown that pre-screening is not associated with improved outcomes or preventing
more cases of FA (Fleischer et al. 2021). Ultimately, providers and parents should engage in shared
decision-making regarding the risks and benefits of testing prior to introduction, to introduce a
diverse and complementary diet around 6 months of life once the infant is tolerating other typical
weaning foods in accordance with the family and cultural preferences. Newer evidence suggests
both early introductions of allergenic foods and aggressive intervention in AD may be beneficial
to preventing food allergies; trials to evaluate the role of these interventions are currently ongoing
(Mancuso et al. 2021).
Evaluation of Skin of Color
AD assessment may be more difficult in darker skin tones due to differences in clinical presentation.
Classic features of AD include erythematous plaques with fine scale found on flexor surfaces; in
contrast, studies have shown patients of various ethnic backgrounds may have differences in the
distribution of skin lesions as well as appearance (Kaufman et al. 2018). For example, patients of
African descent may present with more extensor involvement and patients of Asian descent tend to
have more well-demarcated lesions with increased scaling and lichenification (Noda et al. 2015).
Other differences reported in darker skin tones include papular AD lesions or a lichen planus-like
presentation (Allen et al. 2008). Furthermore, erythema tends to appear more violaceous, brownish
or ashy gray in dark-skinned individuals, which can be more difficult to detect. As such, commonly
used scoring tools such as SCORAD and EASI, which utilize erythema as a key measure of
disease severity, tend to underestimate the degree of disease severity and BSA in darker skin tones.
Additional features should be considered in patients with darker skin, such as the presence of skin
warmth, edema or scale in order to detect underlying erythema.
Evaluation of Steroid Side Effects
Frequent TCS use in patients with AD is not without side effects and special attention should be
given at each visit to evaluate these, particularly in patients with higher burden of corticosteroids
(i.e., in moderate to severe cases). The most frequently seen adverse effects of corticosteroids
include skin atrophy, striae, rosacea, perioral dermatitis, acneiform eruptions and purpura or
telangiectasias (Hengge et al. 2006). Other reported side effects include delayed wound healing,
cutaneous infections or contact dermatitis. Systemic absorption, though relatively rare, may also
occur especially in children, leading to adrenal suppression, hyperglycemia, hypertension, cataracts
and glaucoma (Wood Heickman et al. 2018). The risk of developing side effects with corticosteroid
use increases with a higher burden of corticosteroids, i.e., with the use of higher potency ointments,
larger area of application, prolonged use, occlusion and application to areas of thinner skin.
Furthermore, clinicians should consider the use of corticosteroids for other concurrent diseases,
such as inhaled corticosteroids in asthma and intranasal corticosteroids for allergic rhinitis, both
conditions commonly seen in patients with AD. Particular attention to the adverse effects of TCS
should be given to pediatric AD patients, who have an increased ratio of BSA to weight, and to older
Treatment of Refractory AD
The first-line treatment of AD consists of topical therapies to improve skin barrier function
(emollients to reduce water loss) and decrease inflammation (TCS). Other topical treatments,
including calcineurin inhibitors (tacrolimus and pimecrolimus), phosphodiesterase-4 inhibitors
(crisaborole) and JAK inhibitors (ruxolitinib) have been approved for mild to moderate AD. These
non-steroidal ointments may be utilized as a maintenance therapy to prevent AD flairs given a
Allergic Contact Dermatitis and Atopic Dermatitis 157
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favorable side effect profile compared to long-term TCS use. However, severe cases of AD may not
be controlled with these management strategies, and these patients require additional therapies to
control the disease.
Dilute Bleach Baths
Some studies show that a dilute bleach bath can decrease the severity of eczema (Huang et al. 2009).
In a full bathtub (~ 40 gallons), one can mix 1/4 to 1/2 cup of common liquid bleach (e.g., Clorox)
into the water, making a solution of diluted bleach at ~ 0.005%. Soak in the chlorinated water for
about 10 minutes, pat dry and apply topical medication and/or moisturizer as directed. Bleach baths
can be done two to three times a week or as prescribed by the physician.
Wet Wraps
The application of wet wraps (also known as wet dressings) has been shown to be successful in
treating severe generalized AD flares (Oranje et al. 2006). This therapy consists of applying a
medium-potency TCS and/or emollient to the affected skin, covered with a wet layer and finally
topped with a dry layer. Either close-fitting cotton clothing or bandages may be used as layers,
and specialized garments are available to buy specifically for wet wrap therapy. Wet wraps may be
applied once or twice daily and left in place for two or more hours or overnight if tolerated. This
occlusive method should be used only as short-term therapy; however, it has been shown to result in
increased systemic absorption of the corticosteroid.
Phototherapy
Phototherapy may be an adjunctive treatment for patients with uncontrolled disease. This is done
primarily through narrowband ultraviolet B (NBUVB) or ultraviolet A1 (UVA1) phototherapy
(Garritsen et al. 2014). Typically, NVUVB is administered two to three times per week with
progressive dose increases as tolerated. Phototherapy is generally safe for older children
(> six years of age) and adults; however, it should not be used in infants and younger children
who cannot cooperate with treatment. Potential adverse effects include erythema, blistering, herpes
simplex reactivation and anxiety (Jury et al. 2006). This therapy is generally well-tolerated and
widely available, though cost and increased office visits per week may be prohibitive to certain
patients. Increased risks are associated with UVA radiation, which has been shown to have a higher
risk of developing cutaneous malignancies (Lindelof et al. 1991).
Biologics/Newer Therapies
Newer targeted therapies have emerged in the last several years that have proven to be safe and
effective for the treatment of moderate to severe AD. Dupilumab, a monoclonal antibody that
blocks interleukin (IL) 4 and IL-13 signaling by binding IL-4 receptor alpha, is currently approved
for patients who have failed topical prescription therapies. Tralokinumab an anti-IL-13 has also
been approved for the treatment of moderate to severe AD in adult patients (> 18 years old) whose
disease is not adequately controlled with topical prescription therapies or when those therapies are
not advisable. The initial dose is 600 mg SQ followed by 300 mg every 2 weeks. Differentiating
from Dupilumab, patients below 100 kg who are clear or almost clear after 16 weeks may consider
300 mg every 4 weeks. Abrocitinib and Upacitinib are oral JAK inhibitors approved in the US
for moderate to severe AD in Jan 2022. Ruxolitinib, a topical JAK inhibitor, was approved for
mild to moderate AD who have failed topical therapies. Other experimental agents with specific
cytokine targets (anti-IL-31, S1P Receptor Modulators, CCR4 and OX40 targets) and other oral
JAK inhibitors are currently undergoing clinical trials as are studies on off-label use of biologics
such as Omalizumab for the treatment of AD. Chapter 10 discusses Dupilumab and other newer
therapies in greater detail.
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Other Systemic Immunomodulators
Different types of systemic therapies have been used for the control of pruritus and refractory AD.
The most commonly used options include prednisone, cyclosporine, methotrexate, azathioprine
or mycophenolate mofetil. These treatment options are associated with significant adverse effects
however and should be used only in severe refractory cases in which other standard therapies
have failed.
Glossary of Abbreviations
ACD – Allergic Contact Dermatitis
ACDS – American Contact Dermatitis Society
AD – Atopic Dermatitis
ADCT – Atopic Dermatitis Control Tool
APT – Atopy Patch Test
BSA – Body Surface Area
CAMP – Contact Management Allergen Program
CD – Contact Dermatitis
DBPCFC – Double-Blind, Placebo-Controlled Food Challenges
EASI – Eczema Area and Scoring Index
FLG – Filaggrin
HPLC – High-Performance Liquid Chromatography
ICD – Irritant Contact Dermatitis
IGA – Investigators’ Global Assessment
IL – Interleukin
JAK – Janus Kinase
KOH – Potassium Hydroxide
MCI – Methylchloroisothiazolinone
MF – Mycosis Fungoides
MI – Methylisothiazolinone
NACDG – North American Contact Dermatitis Group
NBUVB – Narrowband Ultraviolet B
NRS – Numerical Rating Scale
PASI – Psoriasis Area and Severity Index
POEM – Patient-Oriented Eczema Measure
PT – Patch Testing
RMS – Raman Microspectroscopy
ROAT – Repeat Open Application Test
SCORAD – Severity Scoring of Atopic Dermatitis
TCS – Topical Corticosteroids
T.R.U.E. – Thin-Layer Rapid Use Epicutaneous
UVA1 – Ultraviolet A1
vIGA – Validated IGA
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50(5): 298–303. doi:10.1111/j.0105-1873.2004.00340.x.
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