Are the concepts of induction of remission and treatment of subclinical inflammation in atopic dermatitis clinically useful?

BACKGROUND: Atopic dermatitis (AD) treatment is often initiated by symptoms or visible erythema. The role of induction of remission or treatment of inflammation that is not visible is unclear.

OBJECTIVE: We investigated whether (1) the notion of subclinical inflammation is scientifically sound, (2) treatment corrects subclinical inflammation, and (3) different strategies for initial clearance of AD affect long-term disease control.

METHODS: We conducted a systematic review based on searching MEDLINE, Embase, the Cochrane register of randomized controlled trials, and the Global Resource of Eczema Trials from inception to the end of October 2012.

RESULTS: Twenty of 26 included studies presented evidence of subclinical inflammation, with a continuum of changes in skin barrier dysfunction, the proinflammatory cytokine milieu, and lymphocytic infiltration from normal-appearing skin to posttreatment lesional skin to active skin lesions in patients with AD. Such subclinical inflammation is improved, with proactive treatment aimed at maintaining remission. Failure to achieve control of AD symptoms with initial therapy was associated with a higher risk of relapse in 14 randomized controlled trials (fluticasone: risk ratio, 1.31; 95% CI, 1.02-1.68; tacrolimus: risk ratio, 1.36; 95% CI, 1.12-1.66). Three trials on systemic therapy/phototherapy suggested that induction of remission resulted in long-term remission without maintenance therapy in approximately 15% of patients.

CONCLUSION: Induction of remission followed by maintenance therapy might prove to be an integral part of a disease-modifying strategy for treating atopic diseases.