Overview of Atopic Dermatitis (AD)

Lawrence F. Eichenfield, MD; Jeffrey M. Bienstock, MD, FAAP; Peter A. Lio, MD; and Elizabeth A. Swanson, MD, provide an overview of atopic dermatitis and review the typical age of onset of disease.

Lawrence F. Eichenfield, MD: Hello, and welcome to this HCPLive® Peer Exchange titled “Expert Perspectives on Collaborative Management of Atopic Dermatitis.” I’m Dr Lawrence Eichenfield from Rady Children’s Hospital–San Diego at the University of California, San Diego. Joining me in this discussion are my colleagues Dr Jeffrey Bienstock of PediatriCare Associates in Fair Lawn, New Jersey; Dr Peter Lio of Northwestern University Feinberg School of Medicine in Chicago, Illinois; and Dr Elizabeth Swanson of St. Luke’s hospital in Boise, Idaho. Welcome, everyone. 

Our discussion focuses on understanding atopic dermatitis in general, providing insight in the management of the skin disorder and the importance of a multidisciplinary approach to care. Let’s get started.

We’re going to start by discussing the basics. What is atopic dermatitis? Is that terminology for atopic dermatitis different from just using the term eczema? Then we’ll discuss what’s typical for the age of onset and some aspects of the course. Is it disease? Is it persistent or recurrent? Let’s start with the first question. Lisa, can you help us with the terminology? How do you define atopic dermatitis, and how do you use that term in relationship to eczema?

Elizabeth A. Swanson, MD: When I’m in clinic, I use the terms atopic dermatitis and eczema pretty synonymously. Technically, atopic dermatitis is a type of eczema. It’s a type of eczema that’s associated with things like allergies and asthma—the whole atopic triad.

Lawrence F. Eichenfield, MD: We know that there are other eczemas that can look similar to or different from atopic dermatitis. But histologically, if you biopsy someone with allergic contact dermatitis to nickel, for instance, in someone who’s got classic atopic dermatitis with morphology and distribution, they look the same under the microscope. They’re eczematous conditions, but most of us use the term eczema to patients synonymously with atopic dermatitis while letting them know what it is to have atopic dermatitis as a label. Jeff or Peter, would you like to weigh in on that?

Jeffrey M. Bienstock, MD, FAAP: Some parents are confused about the difference when they see me in my pediatric practice, and I have to go on and explain. As Lisa said, atopic dermatitis refers more to this triad, where eczema could be any number of things. Sometimes I can’t prove to them until we see a biopsy. However, when they’re with their parent or grandparent, the understanding that the kid has red, itchy skin is usually enough to suffice.

Lawrence F. Eichenfield, MD: Here’s a great example. I’m trying to tell people that if you have an irritant diaper rash, that could be an eczematous condition, but it’s not atopic dermatitis. That’s 1 of the peculiarities of early atopic dermatitis: how the greenhouse effect, humidity, and the diaper usually keep that skin in good shape. 

Let’s move on. What’s the typical age of onset? How often is the disease easy to get under control for long periods of time? How often is it persistent or recurrent?

Elizabeth A. Swanson, MD: Typically, atopic dermatitis will start at a very young age. About two-thirds of patients will have onset before the age of 1 year, and 90% of people will develop atopic dermatitis before the age of 5 years. Only 10% of the diagnoses are made after that, so it tends to start at a young age. There are different levels of severity when it comes to atopic dermatitis in kids. Some kids readily respond to sensitive skin care and occasional use of topical prescription therapies. They can go for long periods of time and do great. Other times, kids struggle more and need more of a consistent medicine regimen to keep their skin under good control.

Lawrence F. Eichenfield, MD: That’s true. Because our audience varies in terms of where they are in the spectrum of care, we need to remember that specialists were getting used to seeing a lot of patients with more persistent and recurrent disease because they’re the ones who generally aren’t doing well in their management. That’s especially true in the first year to year and a half of life from a pediatric perspective. They’re coming in to seek counsel of a pediatric dermatologist, eczema specialist, or allergist. In primary care, we still have patients who may do perfectly fine if you give them a little moisturizer and maybe a little hydrocortisone 2 or 3 times a year. That’s the other end where they don’t have persistent recurrent disease.

I don’t want to leave the age of onset out. I’ll turn to Peter for his thoughts, but don’t forget about adolescent and adult onset.

Peter A. Lio, MD: Yes. When I trained, that was considered a somewhat rare exception, but now I’m seeing increasing numbers of cases of adult-onset atopic dermatitis that are pretty severe. This is a real entity. We’re finally getting our hands around it and understanding it better. We know that a lot of the kids who have it, especially those who are more severe, are probably going to persist. That’s 1 kind of subtype of who we’re seeing in adults: those who had it their whole lives. But in my experience, there is this other de novo type, which is getting a little bit skewed because I’m a referral place. Those tend to be among the most severe cases I see. 

Lawrence F. Eichenfield, MD: We’re seeing it across the spectrum of age.

Jeffrey M. Bienstock, MD, FAAP: As a pediatrician, sometimes I’ve had a parent show me a rash, and I’ll say, “You have what your 3-year-old has here as well. While I can’t send you off to Peter, these are some of the things you could try. If you’re not really improving, you need to speak to your internist, who will probably send you right to a dermatologist.” We see this frequently as these younger kids develop and show signs of atopic dermatitis. 

Lawrence F. Eichenfield, MD: That’s a really good point.

Transcript Edited for Clarity