Expert Nurse Practitioner & Physician Assistant Exchange on Changing Treatment Approaches in the Management of Atopic Dermatitis - Episode 2
Experts in dermatology discuss the clinical presentation of atopic dermatitis, common comorbidities associated with the disease, and its impact on patient quality of life.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Let’s talk about the clinical presentation that you and I have a lot of experience in, but for our colleagues who don’t or those who are in primary care, there’s no one clinical picture across the lifespan of atopic dermatitis. But that distribution is very key to making that diagnosis.
Douglas DiRuggiero, DMSc, PA-C: It is. And I think it can fool people when they present as an infant or a neonate or toddler stage because we classically read that atopic dermatitis presents in flexural areas, the popliteal fossa and cubital fossa, around the base of the neck. But at a young age it’s everywhere. It’s on the face, it can be in the scalp, it can present on the abdomen, the back, the chest. It’s more widespread. And I’ve seen in my clinical practice that as they live with this longer and move into a number of years with the chronicity, it tends to move into those flexural areas, and it has more of a classic presentation a little bit later on. So, you can’t just rely upon that flexural distribution. And I would also say with skin of color, just be careful because it can look a little different. Patients with atopic dermatitis with skin of color, they tend to have more periorbital hyperpigmentation, they have more of a perifollicular papular presentation, they have more lichenification, erythema can look purplish or brown in color, not pink. And then there was that large study that came out of Nigeria showing that the hyperlinear lines in the palm are very prevalent in atopic dermatitis in skin of color. There’s even some nuances within each age category based on their ethnicity and the race.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: And I think adding to that is comorbidities. The key is capturing those. So, one, doing a good history for these patients. And then the second thing is just constantly monitoring them because we know that the quality of life with these patients from childhood into adulthood is compromised. We need to recognize what comorbidities exist. Douglas mentioned atopy. And atopy, often we see a triad of this cytokine, this immune mediated. So often times we see these patients have also environment allergies or hay fever and reactive airway or asthma. It’s not uncommon to see somebody who has all three of those present. And other comorbid conditions that you would like to mention Doug?
Douglas DiRuggiero, DMSc, PA-C: Well, we can’t overlook the impact on the mental health with people who live with a chronic pruritic disorder and atopic dermatitis is no exception to that. We know that they have an increase in anxiety, an increase in depression. In fact, some recent trials that came out in 2019 and 2020 showed that almost one in four patients with atopic dermatitis who have had it for longer than a year have clinical depression. And when you look at suicide alley, it’s one in eight. This is a significant impact on them in terms of how they look, how they feel, if they want to engage in social activities. So that’s a big thing. Other comorbidities include increase in ADHD as well and other hyperactivity disorders increase in atopic dermatitis. And then the big question is like in our psoriasis patients we know that they have a systemic comorbid issues with cardiovascular disease, liver disease, renal disease. We are beginning to see kind of the curtain being pulled away and some recent trials really hinting even more than a hint; pointing towards with both blood studies and imaging studies that there’s an increased risk of cardiovascular disease, not necessarily linked to obesity like in our psoriasis patients, not at the same incidence but it is there as well with potential impact on liver and renal. We’ll just have to wait and see how that pans itself out. Certainly, mental health, asthma, allergic rhinitis, ADHD well-confirmed, cardiovascular becoming more confirmed, and other areas potentially on the horizon. That’s why it’s important to be linked with our primary care folks, making sure these patients are getting the routine screens that they should be getting on an annual basis.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: You know I think a really good point, for example in mentioning the ADHD, I think these are comorbidities that parents for example with children, they might not necessarily associate their atopic dermatitis with these kinds of maybe cognitive or behavioral changes or abnormality, but I think the burden is on us as clinicians to ask those questions. When you have literally a one- or two-year old and you see that they are restless, they actually – how does an infant who is six-months or eight-months old who doesn’t have the fine finger skills, how do they itch. Well, they rub themselves against their car seats and they have raw areas on their external upper arms or their legs or their ankles where they cross their feet and rub it. These children don’t sleep at night. So, think about it. If they're not sleeping at night, how are they performing at school. Their grades at school, staying awake at school, and then that’s just about our patients. Going into adulthood, if they’re not sleeping at nighttime because of the pruritus and the pruritus is really, really the key here. And they may not even know it but their pruritus, if you can’t sleep at nighttime, how can you be alert during the day for your job. The associated quality of life with the workforce and keeping your job can be difficult. But lastly, I think that it’s not just about the patient. It’s about their families because mom and dad have to be called to school, to daycare to pick up the children because they’re having these struggles. The missed work of the families. And then even bigger is our community and dealing with it. Our teachers who are taking care of those children. I think the impact of atopic dermatology or excuse me, atopic dermatitis is so much bigger than just this small snippet that we see in our office.
Douglas DiRuggiero, DMSc, PA-C: Yeah, I couldn’t agree with you more. I mean the fact is that if one person has atopic dermatitis, the entire family has it in terms of its impact. And I think that’s a very true statement. I mean even our studies show, some of the studies that Eric Simpson put out in the last few years, almost 85 percent of patients say that they itch every day. It’s a daily. More than 60 percent said that they have sleep disturbance every night from it. And so, it is a very large impact. Eight out of ten patients say they’re constantly worried about when they’re going to flare next, if they are cleared. So even if they look clear, they’re constantly worried when I am going to erupt again, will it be clear by next weekend for the wedding reception I’m going to. It weighs heavily and that’s why we’re excited about some of these new treatments and things that we will eventually get to and talk about, being able to have long-term suppression has really been a game changer for a lot of these patients.
Margaret Bobonich, DNP, FNP-C, DCNP, FAANP: Thank you for watching HCP Live Peers and Perspectives. If you’ve enjoyed this content please subscribe to our newsletters to receive the upcoming programs and great content right in your inbox. So thank you, everyone. Be safe and live well.
Transcript Edited for Clarity