Atopic Dermatitis Management and Techniques: Beyond the Basics

Diagnosis

  • No clear consensus regarding the diagnostic work-up that should be performed when evaluating patients with AD, particularly adults, has emerged. Diagnostic approaches have large variation.1
  • Chronic prurituis/itch induces scratch behavior, which can serve as a physiologic self-protective mechanism to prevent the body from being hurt by harmful external agents, but is well recognized to damage skin and increase inflammation, further exacerbating prurituis, resulting in the ‘‘itch-scratch cycle.’’2
  • Clinical phenotypes and endophenotypes are characterized by a wide range of heterogeneity in the onset, course, and presentation of AD, as well as in individual comorbidities.
  • The diagnosis of AD remains clinical, as there are no known reliable biomarkers that can distinguish AD from other diseases.3,4
  • Guidelines of care for the management of AD issued in 2014 reported 28 different scales for the measurement of disease severity, without a single gold standard emerging.4

Treatment

  • The mainstay of treatment for AD for decades has been topical corticosteroids.2
  • Crisaborole, a PDE-4 inhibitor is approved for mild to moderate AD in patients 2 and older.
  • For more severely affected subjects, systemically administered broad immunosuppressant drugs (cyclosporine, azathioprine, methotrexate, mycophenolate mofetil, and short courses of systemic corticosteroids) are used.5
  • Until recently, the only new class of medications for treating AD contained the topical calcineurin inhibitors tacrolimus and pimecrolimus, which have been commercially available since 2000 and 2001, respectively.
  • Dupilumab was the first biologic monoclonal antibody (IL-4) approved for AD, and is approved for patients aged 12 and older.6 Additional phase 3 data have also shown 33% achievement of clear or almost clear skin (vs. 11% placebo; P<0.0001) in children aged 6-11 years.7
  • Other biologic agents in development for adults with moderate-to-severe AD include lebrikizumab and tralokinumab, which target IL-13; nemolizumab and BMS-981164, two agents that target IL-31; and others.8

Patient-Related Challenges

  • The propensity toward allergic disorders (asthma, food allergy, allergic rhinoconjunctivitis, and eosinophilic esophagitis) and skin infection (especially Staphylococcus aureus and widespread herpes/eczema herpeticum) is clearly increased.9-12
  • Neuropsychiatric issues (attention-deficit/hyperactivity disorder, depression, anxiety, conduct disorder, autism, and suicidal ideation) have been linked more recently.9-12
  • Assessment of disease severity is further complicated by a disconnect between physicians and their patients. The results of one study suggested that patients and physicians disagreed on the severity level of AD in approximately one-third of cases.13
  • Maintaining motivation and treatment adherence in patients with AD is an important, yet often difficult undertaking.

References

  1. Darsow U, et al. ETFAD/EADV eczema task force 2009 position paper on diagnosis and treatment of atopic dermatitis. J Eur Acad Dermatol Venereol. 2010;24:317-328.
  2. Paller AS, et al. Therapeutic pipeline for atopic dermatitis: End of the drought? J Allergy Clin Immunol. 2017;140:633-643.
  3. Silvestre Salvador JF, et al. Atopic dermatitis in adults: A diagnostic challenge. J Investig Allergol Clin Immunol. 2017;27:78-88.
  4. Eichenfield LF, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70:338-351.
  5. Eichenfield LF, et al. Current guidelines for the evaluation and management of atopic dermatitis: a comparison of the Joint Task Force Practice Parameter and American Academy of Dermatology guidelines. J Allergy Clin Immunol. 2017;139(suppl):S49-S57.
  6. Shirley M. Dupilumab: First global approval. Drugs. 2017;77:1115-1121.
  7. Sanofi and Regeneron’s Dupixent successful in late-stage pediatric dermatitis study. Available at: https://seekingalpha.com/news/3487406-sanofi-regenerons-dupixent-successful-late-stage-pediatric-dermatitis-study
  8. Boguniewicz M, et al. Expert perspectives on management of moderate-to-severe atopic dermatitis: A multidisciplinary consensus addressing current and emerging therapies. J Allergy Clin Immunol Pract. 2017;5:1519-1531.
  9. Schmitt J, et al. Atopic eczema and attention-deficit/hyperactivity disorder in a population-based sample of children and adolescents. JAMA. 2009;301:724-726.
  10. Miyazaki C, et al. Allergic diseases in children with attention deficit hyperactivity disorder: a systematic review and meta-analysis. BMC Psychiatry. 2017;17:120.
  11. Strom MA, et al. Association between atopic dermatitis and attention deficit hyperactivity disorder in U.S. children and adults. Br J Dermatol. 2016;175:920-929.
  12. Thyssen JP, et al. Atopic dermatitis is associated with anxiety, depression, and suicidal ideation, but not with hospitalization or suicide. Allergy. 2018;73:214-220
  13. Wei W, Anderson P, Gadkari A, et al. Discordance between physician- and patient-reported disease severity in adults with atopic dermatitis: A US cross-sectional survey. Am J Clin Dermatol. 2017;18:825-835.