Tips for Treating Atopic Dermatitis Part 2

Atopic dermatitis (AD) is a chronic inflammatory skin disease characterized by itching and the presence of eczematous plaques in symmetrical distribution. It usually appears in childhood and tends to disappear in adolescence but 10% to 30% of cases may persist into adulthood.¹

The diagnosis and management of patients with AD whose disease persists into adulthood poses the same challenges as treating AD in younger ages. The real challenge in diagnosis is when an adult patient presents with a dermatitis “de novo.”

Although adult-onset AD has been described in the literature, I try to make sure it fits some diagnostic criteria and exclude other possible conditions. Therefore, I suggest clinicians:

1. Review the Hanifin and Rajka criteria.^2,3 Does the patient have a personal history of asthma or allergic rhinitis? Does he/she have dry skin?
2. Look at all the affected skin. Some locations can give you clues for considering AD more than others. Are the nipples affected in females? Are hands affected but not feet? Is scalp normal? Is the dermatitis symmetrical?
3. If the dermatitis is generalized or does not have a symmetrical pattern consider biopsy, skin scrapping for scabies, and patch testing. Biopsy will help you rule out serious conditions like cutaneous t cell lymphoma or erythrodermic psoriasis. Patch testing will help you in determining if your patient has an allergic contact dermatitis that is the etiology of the dermatitis or if it is a contributing factor of an underlying AD that you cannot recognize clinically.

Once I exclude all other possible diagnoses then I proceed to treat as AD.

Some things to consider:

1. I recommend fragrance-free bar soaps instead of liquid cleansers. Liquid cleansers contain preservatives and surfactants that can cause sensitization and allergic contact dermatitis.
2. If your patient needs a thick emollient but they do not like the sticky feeling of Vaseline, try cold cream. It is an emulsion of water and certain fats that moisturizes and has a cooling effect. Brand names are Pond’s and Noxzema. They all have fragrances so make sure your patient is not allergic to them.
3. My therapeutic ladder for the treatment of AD is: topical steroids; methotrexate; mycophenolate mofetil (CellCept), and dupilumab (Dupixent).
4. Dupilumab is an excellent treatment for severe AD that had not responded to previous systemic therapies. It works best in patients that meet the criteria of Hanifin and Rajka because that was one of the inclusion criteria used in the original studies. It is not clear the effect it has in adult-onset AD.

________________________________________________________________
Tips for Preventing Further Skin Irritation with Adult AD
Integrative Medicine for Atopic Dermatitis: Q&A With Vivian Shi, MD, Part 1
Novel Insights on Adult Atopic Dermatitis
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Dr. Lugo-Somolinos is professor dermatology, director clinical trials unit, director contact dermatitis clinic at University of North Carolina in Chapel Hill, NC.

References

1. Bingefors K, Svensson A, Isacson D, Lindberg M. Self-reported lifetime prevalence of atopic dermatitis and co-morbidity with asthma and eczema in adulthood: a population-based cross-sectional survey. Acta Derm Venereol. 2013;93:438-441.  

2. Hanifin JM, Rajka G. Diagnostic features of atopic dermatitis. Acta Derm Venereol Suppl (Stockh). 1980; 92:44–47.

3. Atopic dermatitis: Diagnosis recommendations. American Academy of Dermatology website. https://www.aad.org/practicecenter/quality/clinical-guidelines/atopic-dermatitis/diagnosis-and-assessment. Accessed June 28, 2018.