Atopic Dermatitis: Pathophysiology Driving Management Decisions - Episode 5

Presentation and Diagnosis of Atopic Dermatitis

Experts in dermatology discuss the presentation of atopic dermatitis in pediatrics, adolescents, and adults, and the initial diagnosis.

Peter A. Lio, MD: It’s amazing to look at the different presentation in kids and adults. We know that kids tend to have a lot of facial involvement. As they become toddlers, they’ll often get the classical flexural involvement. There are also adults returning with more head, neck, and acral involvement. It’s fascinating to see a change in someone over time.

There was a wonderful paper I read just in the last year or two where they talked about the maturation of the skin barrier. In particular, they were looking at natural moisturizing factor levels. It turns out that the cheeks are slow to mature, and the nose is very quick to do so. They offered this as a potential way of understanding the disease. In the babies, the reason the cheeks are so persistent is because they’re simply immature in terms of natural moisturizing factor, whereas the nose is quite mature.

I love thinking about these differences and connecting that translational work of the basic science to understand these deeper points, along with bringing it to the patient in the clinic, where you can say, “This is why we think this is happening this way to you,” because we can also shape how we’re eventually going to be able to take care of these patients. We’ll be able to say, “This is the right treatment for you, given your presentation.”

We know that a lot of patients go a long time without getting appropriate care. Linda, do you feel that patients often suffer in silence for a long time? Have you met patients where you feel that they haven‘t gotten sufficient care?

Linda Stein Gold, MD: Yes. Peter, as you mentioned, a majority of our patients, probably 90%, manifest the disease within the first 5 years. That means that the first physician is probably going to be the pediatrician. They will hopefully identify it and offer at least a start to treatment, but a lot of people go undiagnosed, especially those with more mild to moderate disease. They think that they have sensitive skin, and their whole family has sensitive skin, so that’s just what they think it is. They try over-the-counter products before they ever try to seek medical care. We have to realize that there is a large percentage of adults, adolescents, and even children, about 2.2 million, who have moderate to severe disease who are not seeking any therapy at all.

Peter A. Lio, MD: It’s incredible, and it underscores how important the pediatricians are, not only for identifying it and doing the basic treatment, but also to refer the patient to a specialist if it’s needed, in the event that they’re not able to get appropriate control. When we look at this, there are some disagreements sometimes, even between specialists, and I wonder what you guys think about when you work with them. For example, an allergist is commonly comanaging these patients. I’ve been lucky, I have a nice cohort of allergists, we’re all like-minded. But at different points in my career and sometimes outside of my control, the allergist that I’m comanaging with has different views, or it is sometimes the primary care physician with different views. I wonder, how do you navigate that when the patient’s hearing multiple different opinions? For example, it even occurs with some fundamental things: which moisturizer to use or how often to bathe, some of these basic things.

Linda Stein Gold, MD: It’s interesting because you can even have a room full of dermatologists, and you can ask the most basic question: Should you bathe frequently or not that frequently? You’ll still be in a room with people who say, “I tell them bathe maybe once or twice a week.” The fundamental questions are, in some people’s minds, very controversial. As you both mentioned, there are comorbidities. A lot of these kids have asthma, they might have food allergies, they might have conjunctivitis, and they might have depression. Ideally, that means that we are caring for these patients with a team approach. It’s important to be on the same page and send the patient the same message. This potentially means talking to their other care providers and making sure. It’s confusing for anybody if we’re getting a mixed message. We must make sure that everybody agrees and sends a common message to the patient and the family.

Peter A. Lio, MD: I like that. We have this disease that requires a multifaceted approach, and we all have to come together for the patient and their family. Emma, at your center [the Icahn School of Medicine at Mount Sinai Medical Center], do you work closely with some other specialists, or do you find that you’re often seeing the patient by yourself and leading the care for the more severe patients you’re seeing?

Emma Guttman, MD, PhD: Yes. We work very closely, and this is one of the benefits of being in a tertiary center. We have a top allergist, a top pulmonologist, and a top psychiatrist. I’m a great believer that it takes multiple specialties to take care of these patients well. I have to say this: It’s not just once or twice that I’ve seen its benefit. For example, I had patient with atopic dermatitis in the severe range, and that patient had depression and was treated by a psychiatrist. Once we initiated treatment for his disease, that cleared the patient, and I would get a phone call from the psychiatrist telling me that the depression also improved for the patient, and they were taken off of medication.

We need to understand that it’s always a balance between what the consequence of the disease is and what the comorbidity of the disease is. We need to keep that in mind, and we definitely need to work together and treat these patients with a multispecialty approach.