Management of Atopic Dermatitis in Adults in Saudi Arabia: Consensus Recommendations from the Dermatological Expert Group

Figures & data

Table 1 Overview of Responses Given by KSA Dermatologists for the Development of Consensus

Survey Questions	Percentage of Expert Response (No. of Experts, N = 12)	Expert Panel Response
Which definition of AD is approved locally?	75% (9/12)	Approval of the AAD definition to guide the clinical practice at the regional level.
Do you routinely use objective clinical tools in evaluating AD severity in routine clinical practice? If yes, which tool do you mostly use: EASI, SCORAD, or IGA/PGA?	92% (11/12)	Either EASI or SCORAD is recommended to be used as per the treating physician’s preference.
Do you routinely use subjective patient-reported assessment tools in evaluating AD severity in clinical settings? If yes, which tool do you mostly use: DLQI, POEM, or Pruritus NRS score? If no, which tool do you recommend as a single tool to be used nationally: DLQI, POEM, or Pruritus NRS score?	75% (9/12)	DLQI is the preferred tool to assess the impact of AD on patients’ quality of life.
To define controlled vs uncontrolled AD, which signs and symptoms matter to you most: pruritus, QoL, eczema bother, sleep pattern, recurrent flares, or others?	92% (11/12)	ADCT may be considered an efficient measure to assess AD long-term control.
Do you recommend ADCT to be used to define control in AD patient management follow-up?	92% (11/12)	ADCT could be considered to define control in AD patient management follow-up.
Which guidelines do you prefer to follow for AD management: American guidelines, European guidelines, or others?	100% (12/12)	In the absence of national or institutional guidelines, reference could be made to the European guidelines in the management of AD.
In your current practice, what is your preferred systemic therapy after topical treatment or in combination with topical treatment for AD management: cyclosporine-A, methotrexate, dupilumab, or others?	100% (12/12)	In AD patients who are not adequately controlled with topical therapy or systemic therapies, the preferred systemic agent for use either alone or in combination with topical treatments is dupilumab*, cyclosporine, methotrexate, phototherapy, or other available systemic treatments^#.

Notes: *Dupilumab is the only approved biologic treatment by the Saudi Food and Drug Authority (SFDA) Health Authority in Saudi Arabia for managing moderate-to-severe AD patients following topical treatment. Of note, the meeting was held before the approval of a newer agent (baricitinib). ^#Other available systemic treatments may include mycophenolate mofetil or oral corticosteroids. Other approved systemic biologics or small molecules were not approved in Saudi Arabia till the date of the consensus meeting held on October 8, 2020.

Abbreviations: ADCT, Atopic Dermatitis Control Tool; AD, atopic dermatitis; DLQI, Dermatology Life Quality Index; EASI, Eczema Area and Severity Index; IGA/PGA, Investigator’s Global Assessment and Physician’s Global Assessment; KSA, Kingdom of Saudi Arabia; NRS, Numerical Rating Scale; POEM, Patient-Oriented Eczema Measure; QoL, Quality of life; SCORAD, SCORing Atopic Dermatitis index.

Figure 1 Flowchart representation of the meeting plan and consensus development.

Abbreviation: AD, atopic dermatitis.

Table 2 Comparison of Objective Clinical Tools of AD

Parameters	SCORAD	EASI	IGA/PGA
Abbreviation	SCORing atopic dermatitis.	Eczema Area and Severity Index (it is a modification of the well-established Psoriasis Area and Severity Index [PASI]).	Investigator’s Global Assessment and Physician’s Global Assessment.
Total number of signs assessed	Six (lichenification, excoriations, edema/papulation, xerosis, oozing/crusting, and erythema).	Four (lichenification, erythema, excoriation, and papulation/edema).	Most commonly three signs are assessed (erythema, papulation/edema, and oozing/weeping). Less often, lichenification, scaling, excoriation, and crusting are evaluated.
Point scale used for scoring	4-Point scale.	4-Point scale.	6-Point scale.
Assessment parameter	The extent and severity of the lesion as well as it incorporates a patient-reported component evaluating sleep deprivation and pruritus.	The extent in four defined body regions (legs and arms, neck and head, torso) and the intensity of four clinical signs.	The severity of clinical signs.
Measurement of the extent of lesions	Extent is measured via a calculation of body surface area, using the “rule of nines” or palmar method, and values range between 0% and 100%.	Lesion extent is measured from 0 (0% involvement) to 6 (90–100% involvement)—1%–9%, 10%–29%, 30%–49%, 50%–69%, 70%–89%, and 90%–100%.	–
Measurement of intensity/severity of lesions	Each sign is scored as: 0 = not present, 1 = barely perceptible, 2 = clearly perceptible, or 3 = very prominent. The maximum score is 103.	Each sign is scored as: 0 = not present, 1 = barely perceptible, 2 = clearly perceptible, or 3 = very prominent. The maximum score is 72.	Each sign is scored as: 0 = clear; 1 = almost clear; 2 = mild; 3 = moderate; 4 = severe; 5 = very severe.
Total score calculation	Extent is calculated by percent disease involvement (A), and symptom severity is measured from 0 to 3 (B) for each sign. Subjective symptoms are quantified by the patient on a visual analog scale (0–10) for each pruritus and sleep loss (C). The total score is calculated as A/5 + 7B/2 + C.	Total score (0–72) = lesional intensity multiplied by the body surface area involved in that region and summed across regions.	–

Abbreviations: EASI, Eczema Area and Severity Index; IGA/PGA, Investigator’s Global Assessment and Physician’s Global Assessment; SCORAD, SCORing atopic dermatitis index.

Table 3 European Task Force on Atopic Dermatitis (ETFAD) of the EADV 2020 guidelines

Forms of AD	Treatment in Adults	Treatment in Children
Baseline: basic therapy	Patient education, emollients, oil bathing practices, or avoidance of irritants and allergens.	Patient education, emollients, oil bathing practices, or avoidance of irritants and allergens.
Mild: SCORAD less than 25	Reactive therapy with topical glucocorticosteroid class II^a or depending on local cofactors: topical calcineurin inhibitors^a, antiseptics including silver^a, silver-coated textiles, or topical crisaborole^b.	Reactive therapy with topical glucocorticosteroid class II^a or based on cofactors in local region: topical calcineurin inhibitors^a, antiseptics including silver^a, silver-coated textiles, or topical crisaborole^b.
Moderate: SCORAD 25–50	Proactive therapy with topical tacrolimus^a or class II or III topical glucocorticosteroids^b, wet wrap therapy, UV therapy (UVB 311 nm and medium-dose UVA), psychosomatic counseling, or climate therapy.	Proactive therapy with topical tacrolimus^a or class II or III topical glucocorticosteroids^b, wet wrap therapy, UV therapy (UVB 311 nm), psychosomatic counseling, or climate therapy.
Severe: SCORAD greater than 50	Hospital admission with the following first choice of therapy: a short course of cyclosporine A^a or dupilumab^a. The additional therapeutic options include: a short course of oral glucocorticosteroids^a; longer course of systemic immunosuppression: methotrexate^b, azathioprine or mycophenolate mofetil^b; PUVA; and alitretinoin^b.	Hospital admission with the following first choice of therapy: dupilumab^a. The additional therapeutic options include: a course of systemic immunosuppression: cyclosporine A^b, methotrexate^b, azathioprine, or mycophenolate mofetil^b.

Notes: Antiseptics or antibiotics are recommended in cases of superinfection. ^aLicensed drugs; ^boff-label treatment drugs. Adapted from: Wollenberg A, Christen‐Zäch S, Taieb A, et al. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children. J Eur Acad Dermatol Venerol. 2020;34:2717–2744. doi:10.1111/jdv.16892.³© 2020 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology. Creative Commons Attribution-NonCommercial License (https://creativecommons.org/licenses/by-nc/4.0/.)

Abbreviations: AD, atopic dermatitis; EADV, European Academy of Dermatology and Venereology; UV, ultraviolet; SCORAD, SCORing atopic dermatitis index.

Box 1 Expert Recommendations

1. The AAD definition may be applied to guide the clinical practice at the regional level. 2. Either EASI or SCORAD is the recommended tool that can be used in practice as per the physician’s clinical judgement. 3. The use of DLQI assessment tool is recommended to evaluate the burden of AD on QoL of patients. 4. ADCT may be considered as an efficient measure to assess patient-perceived, long-term AD control and management. 5. In the absence of national or institutional guidelines, reference could be made to the European guidelines in the management of AD. 6. In patients with AD, who are uncontrolled with topical treatment or systemic therapies, the preferred systemic agents for use, either alone or in combination with topical treatments, are dupilumab*, cyclosporine, methotrexate, phototherapy, or other available systemic treatments^#. *Dupilumab is the only approved biologic treatment by the SFDA Health Authority in Saudi Arabia for managing moderate-to-severe AD patients following topical treatment. Of note, the meeting was held before the approval of a newer agent (baricitinib). ^#Other available systemic treatments may include mycophenolate mofetil or oral corticosteroids. Other approved systemic biologics or small molecules were not approved in Saudi Arabia till the date of the consensus meeting held on October 8, 2020.

Abbreviations: AAD, American Association of Dermatology; ADCT, Atopic Dermatitis Control Tool; AD, atopic dermatitis; DLQI, Dermatology Life Quality Index; EASI, Eczema Area and Severity Index; QoL, quality of life; SCORAD, SCORing Atopic Dermatitis index; SFDA, Saudi Food and Drug Authority.

Wollenberg A, Christen‐Zäch S, Taieb A, et al. ETFAD/EADV Eczema task force 2020 position paper on diagnosis and treatment of atopic dermatitis in adults and children. J Eur Acad Dermatol Venerol. 2020;34:2717–2744. doi:10.1111/jdv.16892

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