Expert Perspectives on Collaborative Management of Atopic Dermatitis - Episode 5
Lawrence F. Eichenfield, MD; Jeffrey M. Bienstock, MD, FAAP; Peter A. Lio, MD; and Elizabeth A. Swanson, MD, discuss whether children outgrow atopic dermatitis and advice for the management of disease.
Lawrence F. Eichenfield, MD: Historically, we’ve had a sense of atopic dermatitis starting early in the first few years and thinking kids would outgrow it. Is that really true? Are there patients who are deferring treatment for their eczema, just waiting and hoping that the kids will outgrow it?
Peter A. Lio, MD: I try to talk people out of doing the watch and wait. We all have that experience of families who are pretty angry. They were told that it will disappear and their child will grow out of it over time. We know that 20% to maybe as high as 30% of pediatric patients will continue to have disease into adolescence and adulthood.
There probably is a spectrum. The more severe patients seem to have a higher risk of having continued disease problems, whereas the milder cases are maybe more likely to simply resolve with time. I always say that it’s a bad idea to watch and wait. Whether it doesn’t go away or eventually does, it’s pretty miserable while it’s happening, so we should do everything we can.
This is a slightly controversial take, but I believe that we can potentially modify the disease. If we’re aggressive in the beginning and get things under control—as we said, it’s a disease of all these positive feedback looks and vicious cycles—it is plausible that we could get it better in such a way that we prevent some of those chronic changes, at least in some patients. Although I fully admit that this is not a proven concept yet. It’s more of just a hypothesis or working idea.
Elizabeth A. Swanson, MD: Along the same lines, there are some new data that suggest that poorly controlled atopic dermatitis opens the door to the development of food allergies. It might actually be the atopic dermatitis that’s contributing to the development of food allergies, rather than food to blame for the atopic dermatitis, which people have thought for years.
With my patients and families who are a little more resistant to the idea of topical steroids and other topical managements, I sometimes say that treating the atopic dermatitis is potentially preventing these other things. What are your thoughts about that, Peter?
Peter A. Lio, MD: I love that. I often talk about that exact point: We had the cart before the horse. We kept saying, “What food is driving this? We’ve got to be careful of these foods.” But now we’ve turned it around. We recognize that there is a concept of transcutaneous or epicutaneous sensitization and getting that skin barrier back down to normal may actually prevent that. We don’t know that for sure, but it’s a working diagnosis or working possibility.
That’s a compelling narrative. My patients really respond to that story. I’m not dismissing food as being a potential drive. Of course we know that the true incidence of food allergy is very heavily correlated with atopic dermatitis and increasing with disease severity. That’s all real, but we can say that we can change not only the outcome of atopic dermatitis but potentially prevent other diseases through good control. At the very least, some of the comorbidities like ADHD [attention-deficit/hyperactivity disorder] and sleep problems.
The sleep problem is very proximally connected to being itchy and uncomfortable. If we get their skin better, then they’re going to sleep better. That’s easy. There’s no controversy there. Maybe that will help prevent some of those other comorbidities that are associated later. Larry, do you agree?
Lawrence F. Eichenfield, MD: Absolutely. I was involved in a very fun point-counterpoint on how early intervention changes the course of atopic dermatitis. I happened to be assigned the pro. It’s a sense we have. It makes sense. I ended up putting together all my slides on how early treatment can affect many things and comorbidities. What was so interesting was that the person who was assigned the con used the same slides and studies and just talked off the other side of them to say what we don’t know.
There was agreement at the end that while it’s not certain that you can necessarily change the life of the disease in any individual, trying to control the disease and have it mostly controlled throughout the course will minimize the impact of the disease. The disease is associated with a whole set of comorbidities, both our traditional atopic comorbidities—food allergy; allergic rhino-conjunctivitis, which we’re certainly more aware of because there’s a very high prevalence in the group; development of asthma over time; environmental allergies—and then this whole set of other comorbidities.
Transcript Edited for Clarity