Advances in the Management of Atopic Dermatitis - Episode 2
Shared insight on the ways a child or adult may present with atopic dermatitis.
Lawrence Eichenfield, MD: How about translating this to the common presentations of the disease in terms of acute eczema, subacute eczema, and chronic forms of AD [atopic dermatitis]?
Raj Chovatiya, MD, PhD: Sure. People aren’t typically going to be walking into clinics saying they have acute, subacute, or chronic eczema, but there are certain findings that you can associate with the earlier phases, acute eruptions, or more chronic phases. When we think about acute dermatitis, we think about erythema and all its shades, vesicles, edema, and even oozing and weeping. Then when you’re making this transition to subacute and acute, that’s when you start to see some of the scaling or crusting we tend to think about with atopic dermatitis.
Finally, when you hit that chronic point, lichenification is classically one of the things we like to think about, the reactive thickening of the skin, and often an excessive degree of scaling from scratching and rubbing. That’s when you can see lichen simplex chronicus, or neurodermatitis, this concept of chronic localized or spread-out patches of lichenification. One more important finding, particularly one we see a lot more in skin of color, are prurigo nodules. That’s another chronic sign associated with chronic and itching and scratching of atopic dermatitis.
Lawrence Eichenfield, MD: The chronic eczemas are those that have some variation. We have patients who come in with very acute flares on top of this chronicity, and they have what I call dry chronic eczema. They come in and they’re remarkably lichenified. Are there any other comments on skin of patients of color? Because I don’t think it’s just prurigo. There’s a lot of lichenoid dermatitis that overlaps, and very lichenified skin. Are there any other comments?
Leon Kircik, MD: Postinflammatory hyperpigmentation is a very big problem with the skin of patients of color. Most of them come in and say they want to get rid of them rather than the eczema itself. It’s always a problem in combination with the lichenification.
Lawrence Eichenfield, MD: Are there any differences in presentation between children and adults? Peter, I’ll bring you in on this if you don’t mind.
Peter Lio, MD: It’s remarkable, especially in infants. We often see a very different distribution from what we do in older kids and adults. The babies almost always have cheek involvement. There was a beautiful paper just a couple of years ago talking about the delayed maturation with natural moisturizing factor in cheeks. That’s the most wonderful translational bridge that I’ve seen in my career. I was like, “That explains why these cheeks are so difficult.” Then there’s often more extensor surface presentation in babies. When we get to the kids, we get the classical flexural involvement, the antecubital popliteal fossa–type pattern. But then we have these adults where it becomes very acral, with hands and feet and then the head-and-neck variant. That’s very perplexing. It’s fascinating to see how an individual over their life can potentially look dramatically different, so much so that sometimes the diagnosis is a little confusing.
Lawrence Eichenfield, MD: The cheeks make me think of infant eczema, and that brings up the question of whether there’s a typical age of onset and what the course of the disease is over time. Lisa, you see a lot of kids in your practice, so why don’t you feed into that question?
Elizabeth Swanson, MD: Predominantly atopic dermatitis will initially appear at a young age. Ninety percent of it appears by age 5, and 60% by age 1. We’re predominantly seeing it early on in the pediatric population. Statistics vary, but about 80% of kids will seemingly outgrow it. However, about 50% of people will eventually develop recurrences of atopic dermatitis over time. Then there’s a smaller percentage of adult patients who note that the first onset of their atopic dermatitis symptoms were as an adult, so that exists as well.
Lawrence Eichenfield, MD: Let’s go through that, because a lot of messaging, especially by primary care providers in the first few years of life, is that this is really common and your kid will outgrow it. Yet we have a lot of school-age and adolescent kids who either haven’t outgrown their eczema or sometimes develop it. Then there are strong data of 7% of adults having atopic dermatitis, some of which is leftover, and some of which is recurrence. But they don’t have the history that they’d had it when they were babies, some of which is really new onset. How do you translate that to your families when you’re dealing with a 1-year-old? What message do you give? What’s your thought of that natural course over time?
Elizabeth Swanson, MD: That’s really important. I see a lot of pediatricians who might not consider treatment of atopic dermatitis valuable and important because of the statistics and the percentage of patients who might eventually outgrow it. That’s a real shame. Even if it’s in this 1-year-old child’s future to eventually outgrow their AD, they’re suffering now, they need treatment now, and their family is suffering now. When I’m giving talks, I always say that I don’t want the rate of outgrowing it to somehow dismiss the importance of adequately treating atopic dermatitis. It’s a horrible thing to have at any age.
Lawrence Eichenfield, MD: Are there any other pearls on how to approach that? I similarly try to be very positive and say there’s a good chance their child will outgrow it. They almost always ask when, and I always say, “I’m not going to tell you,” and then discuss the variability in course. As you said, Lisa, there’s no question that we want to treat it as much as possible to minimize the impact of disease, which we’ll get to shortly.
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Transcript edited for clarity.