Dr Jonathan Silverberg: Insights into Atopic Dermatitis

Jonathan Silverberg, MD, PhD, MPH, is an associate professor of dermatology and director of the patch testing clinic at the George Washington University School of Medicine and Health Sciences in Washington, DC. He is also the director of Clinical Research and Contact Dermatitis. His area of expertise is in inflammatory skin disease, focused on atopic dermatitis (AD) and contact dermatitis. He has a background in advanced management of AD, hand eczema, chronic itch, psoriasis, hidradenitis suppurativa, and other chronic inflammatory skin disorders. His subspecialty revolves around allergy patch testing, phototesting, and photopatch testing. Dr Silverberg met with The Dermatologist to share his insights on AD from his session on the topic at the AAD Summer Meeting 2021.

How can dermatologists recognize the high burden and comorbidities of AD?
The first thing to recognize is that examining clinical signs alone is inadequate to identify the severity and burden of AD. Many patients have mild lesions, but severe itch and sleep loss. These patients warrant more aggressive therapy and go undertreated if dermatologists do not assess the severity of symptoms. There are simple tools that are feasible to use in clinical practice, e.g., the Numeric Rating Scale for itch or patient-reported global severity of AD. These and other patient-reported outcomes can improve the recognition of patient-burden. Some comorbidities, e.g., depression, can be recognized using validated patient-reported outcomes, while others can be recognized using a careful history, review of symptoms, and physical examination.

How do the characteristics of AD differ between children and adults? Any tips as to how to differentiate these characteristics from differential diagnoses?
We recently published a global systematic literature review and meta-analysis of the regional and age-related differences of AD. We found that dermatitis of eyelids, auricle, and ventral wrist, exudative eczema, and seborrheic dermatitis-like features were more common in children, while erythroderma, ichthyosis, palmar hyperlinearity, keratosis pilaris, hand/foot dermatitis, dyshidrosis, prurigo nodules and papular lichenoid lesions (features associated with chronic disease) were more common in adults. Differentiation from other disorders requires careful attention to lesional morphology and occasionally use of supportive tests, e.g., biopsy with histopathologic assessment.

What new therapeutic treatments are on the horizon for AD and what does this say about the evolution of AD treatment of AD?
There are many treatments in late-stage development, including topical (ruxolitinib), oral (abrocitinib, baricitinib, upadacitinib) and injectable (tralokinumab). All 5 of these have multiple completed phase 3 studies under their belt and are awaiting approval in the US by the FDA. There are even more treatments that completed earlier studies or are currently enrolling in phase 3 studies. It is very exciting to have these new tools available in our management toolbox for AD. Each treatment has unique characteristics that fill different unmet needs. I think the next few years of AD research will aim to determine the right patient subsets for each of these new therapies.

Are there any other insights or pearls of wisdom you’d like to share with your colleagues regarding AD?
AD is not psoriasis. AD signs are more subtle than psoriasis, including less pronounced erythema, scale, and edema/papulation. On the other hand, patients with AD tend to experience more intense itch, sleep disturbance, and mental health issues compared to those with psoriasis. It is important for dermatologists not to assess AD severity through the lens of psoriasis.