We Japan have a sad history of steroid bashing in 1980s in the field of atopic dermatitis. Japanese Dermatological Association published treatment guideline of atopic dermatitis at 2000 in order to demonstrate the central role of topical steroid. Afterwards Chaos of atopic dermatitis were partially solved.Skin Research, Suppl. 21:1-3, 2014

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Topical corticosteroid is well known as the most effective topical anti-inflammatory agents for atopic dermatitis at this time. However considerable numbers of patients are suffering from persistent refractory severe dermatitis as a result of inappropriate topical corticosteroid treatment. In such cases there seems to be several pitfalls that prevent physicians to reach the treatment goal such as insufficient comprehension of significance of anti-inflammatory effect, misevaluation of treatment outcome or ignorance of patient's low adherence. To solve those problems topical corticosteroid treatment strategy with conscious of time course to reach the goal was proposed. It is accurate proactive treatment combined with monitoring serum biomarker thymus and activation-regulated chemokine (TARC). This strategy is composed of remission induction followed by control of subclinical inflammation with tapering of topical application frequency. In the treatment schedule of atopic dermatitis physicians should recognize the two-step strategic goal. First step is to induce and maintain remission with anti-inflammatory agent; second step is the final goal of long term remission with minimal anti-inflammatory agent.Skin Research, Suppl. 21:4-10, 2014

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Atopic dermatitis (AD) is developed in variety of ages from new born to over 70 year of age, and goes into remission in a high proportion of cases during childhood, and recurs later in some cases. Therefore it is very difficult to evaluate precise prognosis of AD. In this paper, prognosis of AD is summarized based on many reports of prevalence of atopic dermatitis and long-term follow-up studies. Prevalence of AD is highest at age of 1 year, and more than half of them go into remission at age of 18 months. Prevalence of AD increases at age of three, and reduces until age of 18 years adding 3-5% per year of new AD patients. Prevalence of AD may increase around age of 20 years. Follow-up study revealed that 60% of patients with AD at 20 years of age or more still have dermatitis 24 year later. More than 10% of adult patients with AD have had severe symptom for long term. Poor prognostic factors are as follows: early development of AD, severe symptoms, coexisting with asthma or wheezing, high titer of IgE against multi-allergens, dermatitis on the face and neck in adult patients with AD.Skin Research, Suppl. 21:11-14, 2014

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Steroidal anti-inflammatory drugs (steroids) are used for atopic dermatitis and several intractable diseases. As well as natural glucocorticoids, steroids exert their actions by binding to glucocorticoid receptor (GR). The steroid-binding GR translocates into nuclear and regulates gene expression. Steroids induce the expression of anti-inflammatory proteins and inhibit that of inflammatory proteins such as cytokines/chemokines and inducible enzymes. GR binds to the specific DNA sequences, called glucocorticoid response element (GRE) or negative GRE on target genes to regulate the expression. In addition, the GR inhibits the activity of other transcription factors via tethering to them. Steroid resistance is induced by enhanced inflammatory responses via phosphorylation and degradation of GR and via induction of other transcription factors. Physicians and pharmacists should understand the molecular mechanisms of actions and insensitivity of steroids to avoid side-effects of steroids.Skin Research, Suppl. 21:15-20, 2014

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Sweat is one of major exacerbation factors for atopic dermatitis (AD). The patients with AD show type I hypersensitivity reaction against own sweat. We recently identified MGL_1304 derived from Malassezia globosa as histamine releasing ability in human sweat. The levels of MGL_1304-specific IgE of AD patients were significantly higher than those of normal controls and correlated with the severity of AD symptom. The possible skin care for sweat is wash-out or wipe-out of sweat as soon as possible, especially in summer.Skin Research, Suppl. 21:21-23, 2014

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Although atopic dermatitis is a common skin disease world-wide, the prevalence vary between ethnic groups. In China, AD is not as common as in Japan. However, the prevalence increased in recent years. In 2000, the prevalence of AD in 6-20 year children and young adults were 0.69% . In 2004, the prevalence of AD was 2.78% in children of 1-7 years. In 2012, the cumulative prevalence of AD was reported to be 15.3% in children under 6 years and 10.9% in children of 6-12 years.
Clinically, atopic dermatitis is common in pediatric patients. However, it is not so common in adults. Most adult patients were diagnosed as eczema. Although Williams' criteria was recommended for the diagnosis of AD, the elevation of eosinophil and/or serum IgE level were regarded as the marker of AD by many dermatologists. If adult patients had chronic and generalized eczematous dermatitis without elevation of eosinophil and/or serum IgE level, he or she are often diagnosed as generalized eczema not atopic dermatitis. It might be a long way for Chinese dermatologists to change their idea about eczema and atopic dermatitis.
Inappropriate use of topical steroids had been a problem especially in rural area. Because of the shortage of dermatologists, patients in rural area often buy topical steroid themselves and use it until side-effects occur. Also, general practitioner often prescribe topical steroid without knowing their potency and course of treatment. The side-effects of topical steroid prescribed by dermatologists are rare.
To help Chinese dermatologists to manage AD properly and to avoid inappropriate use of topical steroids, the Chinese Society of Dermatology made a guideline for management of atopic dermatitis in 2008, which included patient education, use of topical steroids and calcineurin inhibitors, UVB treatment and systemic treatment. Topical steroids is the first line treatment. Chinese dermatologists also had a problem of facing negative opinion to steroid from patients. It might be largely due to over-concern about the side-effect that adult patients and parents of AD children are often reluctant or even refuse to use steroid. Dermatologists have to explain quite a lot before their patients agree to use topical steroids. Quite often, the patients stopped using topical steroids by themselves. So over-use and under-use of topical steroid are both problems in China.
Tacrolimus ointment and pemecrolimus cream were the second line treatment for AD. Tacrolimus ointment and pemecrolimus cream are both available in China. The only problem preventing their wide use is the price. For example, the price of tacrolimus ointment and pemecrolimus cream is 5-10 times of steroid creams. They are often prescribed for lesions on face and anogenital area.
To overcome the problems in steroid use, the Chinese Society of Dermatology launched a continuing medical education program, helping dermatologists in underdeveloped area to follow the AD guideline and to use topical steroid and calcineurin inhibitor properly. It turned out that this improved their treatments on atopic dermatitis.

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