Introduction
Atopic dermatitis (AD) is a chronic or chronically relapsing, pruritic, inflammatory skin disease [
1,
2]. AD is one of the most common noncommunicable skin diseases, and is a global issue, with worldwide prevalence estimated at 15–20% in children (aged 6–14 years) and 1–3% in adults [
3]. Prevalence is on the rise, notably in children [
4]. Environmental aspects (e.g., air pollution) may influence the epidemiology of the disease, with the prevalence of AD in preschool children aged 3–6 years reportedly differing between urban and rural areas in China [
5‐
7]. In addition, AD has a major impact on the quality of life (QoL) of patients and caregivers [
8], who frequently experience depression, anxiety, suicidal ideation, and fatigue/insomnia [
9‐
12].
The pathophysiology of AD is complex and is influenced by genetics [
13], impairment of the epidermal barrier [
13], the innate and acquired immune system [
13], and the exposome (i.e., the sum of external factors an individual is exposed to), including the microbiome and pollution [
14]. Due to the heterogeneous nature of the disease, it is characterized by various phenotypes and endotypes, based on and/or impacted by: age [
15], disease severity [
15,
16], chronicity (acute versus chronic) [
15], epidermal barrier impairment (e.g., filaggrin [FLG] status: FLG
+ versus FLG
–) [
15], immune dysregulation (e.g., immunoglobulin E status) [
15], microbiome diversity [
17], and environmental factors (e.g., air pollution) [
5,
7,
18]. Etiological differences between European American, African American, and Asian patients (e.g., intrinsic versus extrinsic AD, immune polarization, epidermal thickness, genetic factors) also exist and influence the characterization of AD [
15]. Stratification of AD by phenotypes and endotypes is therefore important for developing a patient-centric treatment strategy, distancing from the “one-size-fits-all” treatment model [
15].
The treatment of mild-to-moderate AD generally comprises emollients, topical corticosteroids (TCS), and topical calcineurin inhibitors (TCI) [
19], with other therapies (e.g., systemic immunosuppressive agents, phototherapy, biologics) recommended for the management of severe or refractory disease [
20,
21]. Currently, there are geographical differences in the management of AD across Asia, owing in part to significant diversity within the region regarding treatment access, socioeconomic circumstances, and cultural beliefs [
22]. A survey of 255 dermatologists across Southeast Asia (based in Indonesia, Malaysia, the Philippines, Singapore, Thailand, and Vietnam) found considerable variation in how familiar the respondents were with diagnostic criteria, as well as differences in how and when TCS and TCI were used [
22]; this highlights the need for consensus on the optimal treatment regimen [
22]. In addition, complementary and alternative medicines (e.g., herbal preparations) are widely used [
23]. However, the availability of data from randomized trials in patients with AD is limited [
23‐
25], and the level of use in the management of AD in Asia remains unclear.
TCS are recommended as first-line therapy for short-term treatment of acute flares when lesions are unresponsive to basic therapy (and as long-term therapy for the prevention of relapses) [
19]. There are many considerations when selecting a TCS, including galenic formulation, potency, patient age, and area of the body to which medication will be applied [
19]. Although TCS have an important role in the management of AD [
26], they are associated with several limitations. Corticophobia (i.e., worries associated with use of TCS) is a major consideration due to its potential impact on treatment adherence, and is therefore a widespread concern [
27,
28]. In a survey of 300 parents of children with AD conducted in China, 96% were very concerned about the side effects of TCS; as a result, 42% did not use TCS in the event of AD recurrence [
27]. Elsewhere, a study of 200 patients with AD in the United Kingdom found that one-third of patients with concerns about TCS admitted to noncompliance with their TCS regimen [
29]; similarly, a study of 208 patients with AD in France found that approximately 81% of respondents had fears about TCS and 36% reported nonadherence to their treatment [
30].
In addition, use of TCS is associated with skin barrier impairment, skin atrophy, increased risk of skin infections, tachyphylaxis, and misuse/addiction [
31,
32]. As such, TCS are not recommended for long-term management or the treatment of sensitive skin areas, which is notably an issue given the chronic nature of AD and the fact that the disease often affects sensitive skin areas (e.g., face, neck, and flexures) [
1,
19]. Sensitive skin areas therefore require further consideration when it comes to therapeutic decision-making, and there is a need for TCS-sparing treatment strategies, based on different clinical manifestations (e.g., age, severity of disease).
TCI offer a valid alternative, as they have similar efficacy to low-to-mid potency TCS, and are not associated with the same limitations, such as skin barrier impairment and skin atrophy [
33‐
35].
The aim of this article is to propose a practical TCS-sparing treatment algorithm for the management of infants, children, adolescents, and adults with mild-to-moderate AD, to guide daily clinical practice in China. The algorithm focuses on the role of TCI in the treatment of mild-to-moderate AD, incorporating a TCS-sparing approach, and identifying the role of pimecrolimus for sensitive skin areas. The algorithm has been structured so that primary care physicians (who regularly see patients with AD), as well as pediatricians and dermatologists, can use it. It is intended to support evidence-based treatment guidelines available at both the international and national level.
Acknowledgements
Disclosures
Zuotao Zhao reports personal fees from Novartis, Pfizer, Astellas, Galderma, Meda Pharma S.p.A., a Viatris company, Bayer, LEO, GSK, Janssen, and ALK Pharma, outside the submitted work. Xing-Hua Gao reports personal fees from Novartis, Pfizer, Astellas, Meda Pharma S.p.A., a Viatris company, Sanofi, Lilly, Bayer, LEO, GSK, Pierre Fabre, and Janssen, outside the submitted work. Wei Li reports personal fees from Sanofi, Pfizer, Lilly, Novartis, LEO, Pierre Fabre, Meda Pharma S.p.A., a Viatris company, Astellas, and Galderma, outside the submitted work. Hua Wang has nothing to disclose. Yunsheng Liang reports personal fees and other from Sanofi and Pfizer, and personal fees from Novartis, Astellas, Janssen, LEO, and Meda Pharma S.p.A., a Viatris company, during the conduct of the study. Jianping Tang reports personal fees from Meda Pharma S.p.A., a Viatris company, during the conduct of the study. Xu Yao has nothing to disclose. Hua Zhao reports personal fees from Meda Pharma S.p.A., a Viatris company, during the conduct of the study. Thomas Luger reports grants and personal fees from Meda Pharma S.p.A., a Viatris company, during the conduct of the study.