Prevalence of atopic dermatitis is on the rise, ranging from 10% to 20% in the United States and other developed countries.1
However, managing the severity of atopic dermatitis is no easy task. Flares come and go, and the reasons for uncomfortable exacerbations can be complex and hard to pinpoint. Making treatment more challenging is “steroid phobia,” also known as “corticosteroid phobia,” a concern among many parents and others about the safety of topical corticosteroids, the mainstay treatment for children with moderate to severe disease.2
Finding the best ways in which to manage patients with atopic dermatitis is critical, not only to relieve physical symptoms of the disease, but also to mitigate the psychosocial impact on children’s and families’ lives, according to Amy Paller, MD, professor and chair of dermatology and professor of pediatrics at Northwestern University Feinberg School of Medicine, Chicago, Illinois.
“We’ve always known that there are severe psychosocial effects.3 [These range] from the highly visible lesions to the fact that these children don’t sleep well, if they sleep. It’s difficult in school because they’re falling asleep and that makes them different. They have attentional issues at school. They don’t feel comfortable playing or doing sports because they’re so much itchier when they get hot,” Paller says. “There are also neurocognitive issues with atopic dermatitis.”
Quality of life is profoundly affected in children with moderate to severe disease, according to Paller.4 “[T]he quality of life reported [by these kids] is [similar to] what we see with many of the chronic diseases, such as diabetes and seizures,” she says.
Lawrence F. Eichenfield, MD, chief of pediatric dermatology and professor of pediatrics and medicine (dermatology), at the University of California, San Diego, and Rady Children’s Hospital San Diego, California, says that atopic dermatitis advances and research have improved understanding of the epidemiology and pathogenesis of the disease.
“Over the last several years, identification of mutations in the skin responsible for skin barrier dysfunction, associated with the dry skin of eczema, as well as a setup for its inflammation, have been emphasized,” says Eichenfield, an author on the atopic dermatitis guidelines released in 2014 by the American Academy of Dermatology.
“Research has shown there are mutations in certain genes expressed in the epidermis that fundamentally influence the skin barrier function. Filaggrin gene mutations have been shown to have a strong predictive value for higher risk of development of atopic dermatitis, as well as increased rates of asthma, allergic rhinitis, [immunoglobulin E] sensitization, as well as more severe atopic dermatitis that can persist into late childhood and adulthood,” he says.
Eczema is a phenotype. Classic atopic dermatitis usually starts in early childhood. Whether adult onset atopic dermatitis is the same or a different disease is unclear, according to Elaine C. Siegfried, MD, professor of pediatrics and dermatology, Saint Louis University, Missouri. Also, the jury is still out on whether atopic dermatitis is a primary inflammatory disease or a primary barrier disease, she says.
“The pathogenesis is likely related to dysfunction in both systems. For some it’s probably primary inflammatory and for other people it’s probably primary barrier,” Siegfried says, “but the role of the cutaneous microbiome is being increasingly recognized as an important cofactor for both skin barrier and immune function.”
From a clinical standpoint, the knowledge about skin barrier dysfunction reassures physicians that an approach emphasizing good skin care and liberal use of moisturizers can help to minimize the impact of the disease, according to Eichenfield.
Infection can occur with atopic flares, but antibiotics are better left to treat skin infections, rather than try to prevent them, says Eichenfield. “Generally, in nonaffected atopic dermatitis the broad use of antibiotics is not recommended. However, infected eczema might benefit from systemic treatments,” she says.