Drs Bhatia and Lamb discuss the case of a 12-year-old child with asthma and how they would manage his disease.
Neal Bhatia, MD: That brings us to the second case I’m going to give you guys. This is a patient with skin type 5. He’s a 12-year-old boy with asthma and relapsing atopic dermatitis. He’s been to the dermatologist many times with itchy swollen flares—some on his face, some on his body. They talk about the rash and the constant itching. The school nurse even made the initial diagnosis at 6 years of age, but it was first thought to be an allergic reaction to something. The primary care doctor thought he was having food allergies that led to the rash. He was treated with elimination diets and a bunch of nonpharmacological agents, and he got over-the-counter antihistamines. The itching subsided, but he still had a lot of activity, cutaneously of course.
Even in the last year, he started to see more involvement of his legs and more thickening of the skin. He was treated with topical steroids, then tacrolimus ointment. The itching and swelling didn’t go away. He was referred to another dermatologist. The patient’s family is uninsured, which is unfortunate, but also they’re searching for employment. The father has asthma, and an older brother has allergic rhinitis. Obviously the family history is going to be strong. This springboards from what we talked about in all the different mechanisms of therapy and all the different approaches.
Angela, where do we go from here? Between chasing doctors and bad advice, and what you brought up before about the diagnosis and the skin-of-color patient making an accurate diagnosis. what prose could we share? What talking points should we have?
Angela Lamb, MD: Clearly, this person has an atopic history. They have asthma. It sounds like they probably do have also some seasonal allergies. As you said, in darker skin tones, it’s very difficult to get that diagnosis. Our atopic dermatitis tends to be more papular. It tends to present with lichenified erythema. As Omar mentioned, sometimes people don’t even recognize erythema because it’s not the classic bright red. It’s more of a dusky maroon. Culturally, sometimes there’s a sense that there must be a root cause. It’s atopic dermatitis, which certainly may be exacerbated by contact allergies or food allergies 100%, but that doesn’t necessarily mean that the reason that your child has atopic dermatitis is because of something they’re eating or because they need to go on a severe elimination diet.
This person, because they have atopic dermatitis as well as the asthma, is a perfect candidate for dupilumab. Right out of the gate, even on the first visit, that’s what I’d be discussing with them. The patient has such a long history. It would address both the asthma and the atopic dermatitis. Also, educate them about that. I’d probably also refer this person for patch testing and make sure they’re seeing an allergist, just to check those boxes. We know from all the studies that even people who eliminate all those allergies still have atopic dermatitis. Anecdotally, I see many people whose allergic contact is making their atopic dermatitis worse, or a severe food allergy is making their atopic dermatitis worse. The more things we can eliminate from all the things that are contributing, the better.
Neal Bhatia, MD: Those are all excellent, especially the collaboration with an allergist. I’ve found that when allergists are managing alone, no disrespect to them, but we should be partnering with them and vice versa. We should talk about top-down care, the right testing, confirming food allergies, and all those other compounding factors. I have a lot of Filipino patients, a lot of Japanese patients, and they all worry about foods. Food is the No. 1 driver for a lot of the elimination as well as your protection of the patient. There’s a lot that goes with that.
Transcript Edited for Clarity
Case 2: Patient with Dark Brown Skin
A 12-year-old boy with Fitzpatrick skin type (FST) V and a history of asthma and relapsing AD presented to the dermatologist with itchy swollen rashes on his body.
The rashes and constant itch were initially noticed by the school nurse at age 6 year but was thought to be an allergic reaction to something outside. His PCP initially suggested that he was suffering from food allergies that led to rashes. He was treated with non-pharmacological agents and an elimination diet. After multiple follow-ups, his PCP recommended over the counter antihistamines to help with the itch. While the itch subsides with antihistamine treatment, he continued to have brownish-gray patches over his body.
Since last 1 year, he started to see irritation and swelling of rashes on his legs and thickening of skin in other areas. He was treated with topical corticosteroids followed by tacrolimus for a few months, but the irritation and swelling did not go down. He was then referred to the dermatologist for the next steps. The patient’s family is currently uninsured but are actively searching for employment with health insurance. His father suffers from asthma and his older brother suffers from allergy rhinitis.