Adults with atopic dermatitis are not just big kids

Jonathan I. Silverberg, MD, PhD, MPH, discusses the prevalence of atopic dermatitis in adults.

Many clinicians think of atopic dermatitis (AD) as a childhood disease. Even dermatologists may not realize that the prevalence of AD in adults is only slightly lower than in children. The difference is about 10 percent in adults versus 12 percent in children.

“The similarity in prevalence for adults and children suggests that childhood AD persists more commonly than we think or that adult onset AD occurs more commonly than previously thought, or both,” said Jonathan I. Silverberg, MD, PhD, MPH, director of the Northwestern Medicine Multidisciplinary Eczema Center and assistant professor of dermatology, preventive medicine, and medical social sciences at Northwestern University Feinberg School of Medicine.

Childhood AD tends to exhibit on the face, hands, extensors, and flexors, depending on age, Dr. Silverberg said March 5 during “Atopic Dermatitis in Adults: Not Just Big Kids” (D005). Adults tend to exhibit more head, neck, hand, and foot lesions.

Differential diagnosis of AD can be difficult in adults. It is often confused with allergic contact dermatitis, which requires prior sensitization, and psoriasis, which generally has thicker scale and darker red color, but can be difficult to distinguish from AD. Nail findings associated with psoriasis might be a helpful clue, he said.

Clinicians should always consider medication history in adults with AD. Drug-induced AD can be difficult to distinguish from adult onset AD, Dr. Silverberg explained. Calcium channel blockers or thiazides are often culprits.

Biopsy cannot make every diagnosis, he added, but may be able to narrow the diagnosis to eczema. It is often necessary to rule out other disorders, such as mycosis fungoides, cutaneous T cell lymphoma, or lichenoid disorders in skin of color.

Assessment of AD severity is similarly vague. Many different assessment tools have been used, but none are common in clinical practice. Assessment of AD severity is largely based on physician judgment and experience based on the number and size of lesions, the extent of disease, the presence of severe symptoms, such as itch, pain, sleep disorder, and mental health, or some combination of symptoms.

Adults with AD are likely to have lost six or more workdays annually to their disease, have more medical visits, more trips to the emergency department, and more hospitalizations than the typical adult. Adult AD patients also spend nearly $500 more out-of-pocket annually compared to hypertension and diabetes.

Adults with AD have a lower irritant threshold, which results in more eczema, hay fever, urticaria, dermatographism, and allergic contact dermatitis. The most common adult sensitivity by patch testing is to formaldehyde releases and other common preservatives, as well as cocamidopropyl betaine and other common surfactants. Adults with AD also have significant rates of sleep disturbances, mental health issues, and impaired quality of life.

Avoiding triggers is a prerequisite for any treatment, Dr. Silverberg said. That can include cold and hot temperatures, dry air, humid air, tight clothing, fragrances, boredom, and stress.

Current topical treatments include emollients, corticosteroids, calcineurin inhibitors, antimicrobials, and antihistamines. Systemic therapies include corticosteroids, antimetabolites, purine analogs, interferon gamma, and antibiotics. Most of these systemic agents are used off-label, he cautioned.

Another alternative is light therapy, including narrowband UVB, excimer lasers, and UVA/PUVA. These therapies are off-label but are commonly used, often successfully, Dr. Silverberg said.

Crisaborole, a PDE-4 inhibitor, is one of the most promising emerging therapies. Dupilumab, which inhibits IL-4 and IL-13, also shows promise. It shows good results as a single agent but is more likely to be used in combination with topical corticosteroids, topical calcineurin inhibitors, or crisaborole.

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