A concept for integrated care pathways for atopic dermatitis—A GA 2 LEN ADCARE initiative

**Background:** Atopic dermatitis (AD) is a common chronic inflammatory skin disease with a lifelong disposition and variable clinical manifestations. Prevalence rates vary geographically, with cross-sectional surveys reporting point prevalence from 2.1% to 4.9% in adults and 2.7% to 20.1% in children. The Odense Adolescents Cohort Study found that AD persisted into adulthood in 50% of those diagnosed in school age. A nationwide Norwegian health registry indicates an increasing incidence of pediatric AD, especially in children under 1 year, with more than 1 in 6 children under 6 years affected at some point. AD is a systemic inflammatory condition involving filaggrin deficiency-induced skin-barrier disruption and microbiome alteration. It is associated with significant comorbidities, including sleep problems, mental health disorders (e.g., attention-deficit/hyperactivity disorder, anxiety, depression, autism, suicide), and other atopic and non-atopic conditions. Despite existing evidence-based guidelines, treatment strategies in daily practice vary widely and often deviate from guidelines. Integrated care pathways (ICPs) offer a structured multidisciplinary plan that can enhance guideline recommendations by combining interventions, integrating quality assurance, and describing coordination of care. The GA²LEN ADCARE network initiated this project to develop AD-ICPs that address gaps in real-world management.

**Methods:** The AD-ICP working group consisted of stakeholders from the GA²LEN ADCARE network and partners. The development process involved a series of subgroup workshops and meetings held in 2020 and 2021. An online conference on March 26, 2020, formed the core of the working group, followed by a second meeting on August 12–13, 2021, with dedicated workshops on different topics. The document was then circulated among all GA²LEN ADCARE centres. Stakeholders included patients, pharmacists, nurses, general practitioners, pediatricians, specialists, tertiary referral centres, hospitals, academic research institutions, the pharmaceutical industry, and patient organisations. The ICPs were designed to be flexible, allowing patients to enter at any level depending on AD severity, available resources, and economic factors.

**Key Results:** The AD-ICPs outline diagnostic procedures, possible comorbidities, and treatment options, including differential approaches for the pediatric population. Diagnostics in primary care should be based on clinical criteria including itching and sleep disturbance using visual analogue scales and overall quality of life. Specialist referral criteria consider distribution pattern, need for daily treatment, high potency steroids, response to treatment, recurrence, infections, comorbidities, age of onset, and impact on quality of life. Scores like SCORAD, EASI, POEM, or DLQI/cDLQI are reserved for specialists. Comorbidities include atopic (e.g., asthma, food allergy) and non-atopic conditions (e.g., autoimmune diseases, cardiometabolic diseases, mental health disorders). Ocular comorbidities affect 25%–42% of AD patients and are often underdiagnosed. Topical treatment includes emollients, emollients 'plus', corticosteroids, and calcineurin inhibitors. Systemic treatments are needed for moderate-to-severe AD not controlled by topical therapy. Licensed systemic therapies include dupilumab (approved for adults and children ≥6 years), tralokinumab (adults), baricitinib (adults), upadacitinib (adults and children ≥12 years), abrocitinib (adults), and cyclosporin A (≥16 years in Germany and Austria). The AD TREAT Germany registry shows dupilumab is the most prescribed systemic drug. New and emerging treatments include JAK inhibitors and biologics. For pediatric populations, cumulative incidence is 22.8% in children aged 0–6 years, with lifetime prevalence of 21.3% in adolescents and 34.1% in adults. The role of pharmacists includes improving adherence, reinforcing physician messages, and preventing prescription mistakes. The ICPs also address limited resources in lower- and middle-income countries, the need for personalised approaches, and the impact of climate change on AD.

**Clinical Implications:** The AD-ICPs provide a multidisciplinary, globally applicable framework that can improve diagnosis, treatment, and patient feedback in AD management. They address critical unmet needs, including improved access to care, training of specialists, implementation of educational programs, assessment of climate change impact, and fostering personalised treatment approaches. By integrating various stakeholders and allowing flexible entry points, the ICPs aim to enhance guideline adherence and real-world outcomes. The initiative supports the EU efforts on healthy and active aging (AHA) and promotes the use of digital tools like the MASK air app for comorbidities and AD. The ICPs are intended to be dynamic, adapting to new evidence and regional differences, ultimately paving the way for better management of AD globally.