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The Decade of Atopic Dermatitis 

 

Zelma Chiesa Fuxench, MD, presented on novel insights into the pathogenesis of atopic dermatitis (AD) and on promising new treatment options for patients with AD, at the Interdisciplinary Autoimmune Summit 2018.

In her presentation, Dr Chiesa Fuxench discussed the prevalence, comorbidities, and impact on quality of life of AD on patients, as well as recent advances in the pathophysiology and treatment options. 

Adult-onset AD occurs more frequently during the third decade of life and affects between 3.2% and 10.7% of adults in the United States. About 30% of all cases of AD occur in the adult population, she said, however adult-onset AD is considered more rare than pediatric AD.1 Also, the presentation of AD in adults differs slightly from the presentation in children, said Dr Chiesa Fuxench. AD can affect the face, neck, trunk, hands, and feet of adults, and patients with skin of color can have different presentations (Figures 1 and 2).

eczema feet

Figure 1. Atopic dermatitis on feet. Photo courtesy —Dr Chiesa Fuxench

Adults with AD have a higher rate of other atopic diseases, including nasal allergies, hay fever, and asthma,2 as well as cardiovascular diseases and cancers, she said. In addition, anxiety, depression,2 attention deficit disorder, and autism spectrum disorder are associated with AD. 

Along with these comorbidities is the direct impact of AD on patients’ quality of life. Adults with moderate to severe AD have reported significant sleep disruptions, decreased confidence, and having to undergo lifestyle modifications because of their disease,3 Dr Chiesa Fuxench said. In The International Study of Life with Atopic Eczema study,4 14% of adult patients believed that their career progression had been hindered by AD, she added. 

She suggested that in clinical practice clinicians can use open-ended questions and other assessments for clinical outcomes and disease severity to determine the impact of AD on patient’s lives. 

Various studies have shown that the pathogenesis of AD includes immune dysregulation, allergen presentation, and Th2 sensitization with skin inflammation and epidermal barrier dysfunction, said Dr Chiesa Fuxench.5-10 In addition to proinflammatory cytokines, AD involves activation of the Janus kinase/signal transducers and activators of transcription (JAK/STAT) pathways. 

eczema chest

 

Figure 2. Different presentations of atopic dermatitis in patient with various skin tones. Images: Photo courtesy —Dr Chiesa Fuxench

When considering treatment, said Dr Chiesa Fuxench, the goal is to decrease the rate of acute flares and disease exacerbations, and to have a long-term plan to maintain a state in which symptoms are mild with minimal to no impact on quality of life. 

“Education is key,” she said. Engaging the patient and discussing the patient’s preferences is important for developing a treatment plan, along with providing written instructions and skin care recommendations. 

Proactive treatment includes “a combination of predefined, long-term, low-dose, anti-inflammatory treatments applied to previously affected areas of the skin on a regular schedule in addition to emollients on the entire body” to help reduce flares and maintain the skin barrier, she said. 

In addition, potentially promising new systemic treatment options for AD include cytokine or cytokine receptor inhibitors, phosphodiesterase-4 inhibitors, and the JAK/STAT pathway inhibitors. Dupilumab (Dupixent) is the first FDA-approved systemic treatment for AD, she said, but other therapies are being investigated, including nemolizumab, tralokinumab, lebrikizumab, and ustekinumab (Stelara).

The last decade saw a surge in newer understandings and treatment options for psoriasis. This will be the decade of AD, according to Dr Chiesa Fuxench. 

References

1. Hanifin JM, Reed ML; Eczema Prevalence and Impact Working Group. A population-based survey of eczema prevalence in the United States. Dermatitis. 2007;18(2):82-91.

2. Whiteley J, Emir B, Seitzman R, Makinson G. The burden of atopic dermatitis in US adults: results from the 2013 National Health and Wellness Survey. Curr Med Res Opin. 2016;21:1-7.

3. Simpson EL, Bieber T, Eckert L, et al. Patient burden of moderate to severe atopic dermatitis (AD): Insights from a phase 2b clinical trial of dupilumab in adults. J Am Acad Dermatol. 2016;74(3):491-498.

4. Zuberbier T, Orlow SJ, Paller AS, et al. Patient perspectives on the management of atopic dermatitis. J Allergy Clin Immunol. 2006;118(1):226-232. 

5. Palmer CN, Irvine AD, Terron-Kwiatkowski A, et al. Common loss-of-function variants of the epidermal barrier protein filaggrin are a major predisposing factor for atopic dermatitis. Nat Genet. 2006;38(4):441-446.

6. Fallon PG, Sasaki T, Sandilands A, et al. A homozygous frameshift mutation in the mouse Flg gene facilitates enhanced percutaneous allergen priming. Nat Genet. 2009;41(5):602-608.

7. Paternoster L, Standl M, Waage J, et al. Multi-ethnic genome-wide association study of 21,000 cases and 95,000 controls identifies new risk loci for atopic dermatitis. Nat Genet. 2015;47(12):1449-1456.

8. Tamari M, Hirota T. Genome-wide association studies of atopic dermatitis. J Dermatol. 2014;41(3):213-220.

9. Brunner PM, Leung DYM, Guttman-Yassky E. Immunologic, microbial, and epithelial interactions in atopic dermatitis. Ann Allergy Asthma Immunol. 2018;120(1):34-41.

10. Napolitano M, Megna M, Patruno C, Gisondi P, Ayala F, Balato N. Adult atopic dermatitis: a review. G Ital Dermatol Venereol. 2016;151(4):403-411.

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