Advances in the Management of Atopic Dermatitis - Episode 3

Persistent Atopic Dermatitis and Flare-ups

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Considerations for persistent atopic dermatitis vs outgrowing disease, followed by triggers that can result in flare-ups.


Lawrence Eichenfield, MD: What’s your sense of persistent disease? Can you predict persistent disease at different ages? How do you figure out if you’re going to have 1 of those patients in whom 2 weeks of a good topical therapy fixes them vs frequent recurrence or persistence?

Elizabeth Swanson, MD: The statistics show 80% of kids outgrowing it at age 8, and we know that patients with bad atopic dermatitis, moderate to severe atopic dermatitis, are less likely to outgrow it. If I’m seeing a patient at age 9 and they haven’t outgrown it and it’s moderate to severe, there’s a low chance—not 0—that they’ll outgrow it. However, in a 1-year-old, I’m not sure if this patient is going to fall in the 80% outgrowing rate and when that will happen.

Lawrence Eichenfield, MD: Leon, what are some triggers you think cause flare-ups? Do you think there’s underlying inflammation without visible skin lesions?

Leon Kircik, MD: Let me answer the second question first. There’s definitely underlying inflammation, and we see that in most of the diseases, including inflammatory cutaneous disorders, acne, and psoriasis. There’s underlying inflammation, and then there are the clinical lesions that come. I always tell my patients it’s a chronic disease. We have to treat it continuously, but then it becomes so difficult to treat when you don’t see what you’re treating. That’s really hard, including for the providers. We tell people, “If you don’t see anything, stop it until it comes back.” There’s a lot of back and forth of how to maintain the clearance. That’s a big problem.

There are a lot of triggers: dry skin, irritation, excessive washing, and especially soap. I always think all the acid mantle of the skin is so important. I used to hear that from the old-timers, and we forget that. We have to maintain that acidic pH of the skin. Tap water has a pH of 7. Just using tap water is going to trigger disease. Using the soaps, cleansers, and moisturizers are all important to prevent those triggers. Using things that are the opposite of what they’re supposed to do is a problem.

The other thing I find very interesting is contact dermatitis, especially to topical steroids. We keep using them, and then they don’t get better. I’m like, “Why? Is my diagnosis wrong, or are we doing something wrong?” I see a lot of topical steroid contact dermatitis in those kids. There are a lot of trigger factors.

Then we talked about adults and the pediatrics, but we didn’t talk about differences in ethnicities or racial skin. I see a lot of Black kids who sometimes get worse in the summertime with sweating in the heat vs White kids who actually get much worse in the winter with the cold weather. We don’t talk about that much. There are a lot of triggers that we can prevent if we know who’s prone to them and what’s going to cause it.

Lawrence Eichenfield, MD: Certainly, we haven’t even discussed allergic triggers. There are especially environmental allergens that can do that. You mentioned contact dermatitis, which is a big overlap that’s both a separate diagnosis and an exacerbator. Then there’s the environmental aspect from pollution. We always thought that. We did a big review article about a year ago with Vivian Shi and colleagues. Then the data came out of the Camp Fire [in 2018], 1 of those big fires in Northern California. This was in San Francisco. The fire was about 120 or 140 miles away, but the air had moved south and hung out. They noticed that there was an increased number of visits for itch and atopic dermatitis during the time course, which is a clear example of environmental change—in that case, transient for a while—that triggered a set of presentations for patients with eczema.

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Transcript edited for clarity.