Why to Assume AD Diagnosis in Adults

In a presentation at New Wave Dermatology Conference, Matthew Zirwas, MD, delved into why atopic dermatitis (AD) should be the first condition that comes to mind when an adult patient presents with dermatitis, why presentation is different in pediatric and adult patients, and why treating AD is about more than quality of life.

Yes, it probably is atopic dermatitis (AD), according to Matthew Zirwas, MD. “Based on the AAD guidelines, essentially every adult patient with dermatitis has AD and that is not our experience with pediatric patients with AD,”1 said Zirwas, associate professor at the Ohio University Heritage College of Medicine in Athens, Ohio, in a presentation at the recent New Wave Dermatology Conference.2

“In the past, the assumption was that dermatitis in adult patients was not AD, and that AD was only the diagnosis if the patient met rigid criteria: A childhood history of ‘eczema,’ AD comorbidities and a history of the dermatitis being flexural. That was wrong,” said Zirwas. He laid out best practices for diagnosing AD in adult patients:

Understand That the Criteria is Nonspecific in Adults

Zirwas recommended beginning with the assumption that every patient with dermatitis has AD. “Apply the diagnostic criteria the FDA uses in AD clinical trials,” he said. “Essentially, the necessary features to diagnose AD areitchy, chronic, spongiotic dermatitis that spares the groin and axilla and which you do not think is scabies, seborrheic dermatitis, contact dermatitis, icthyoses, cutaneous T-cell lymphoma, psoriasis, photosensitivity dermatoses, immune deficiency diseases, or erythroderma from other causes,” he said. If the patient does not meet the criteria and therefore does not have AD, they should be worked up and/or treated for contact dermatitis, seborrheic dermatitis, or scabies, according to Zirwas.

Learn Why AD Presents Differently in Adult Vs Pediatric Patients

“AD in children tends to present in a very specific way: flexural with a strong association with IgE-mediated disorders,” said Zirwas. So why is the condition so much more variable in adults? “Little kids’ lifestyles, diets, stress, microbiomes, and environments in general are relatively similar from kid to kid, whereas adults have accumulated massive variability in their microbiomes and epigenetics and immune exposures, let alone their environmental exposures,” he added. As to why AD does not always develop in childhood, Zirwas pointed out that after about age 30, overall barrier function declines and skin inflammation increases. The reasons may be simpler—perhaps the patient simply did not encounter their AD triggers until adulthood.

Know Why it Matters

Moderate to severe AD needs to be controlled not only for patient comfort, but to address serious infection risks.3 New AD-specific therapies broaden the armamentarium for treating the condition and lessening those risks, but many of them are not effective for other types of dermatitis. Zirwas noted that before these new options were available, the tools to treat AD were identical to those for unspecified dermatitis, so precise diagnosis did not affect treatment efficacy.

Disclosures:

Zirwas is a speaker for Genentech, Novartis, Sanofi, and Regeneron Pharmaceuticals. He is a consultant for Sanofi/Regeneron Pharmaceuticals, FitBit, L’Oreal, LEO Pharma, Pfizer, Eli Lilly and Company, Arcutis Biotherapeutics, Ortho Dermatologics, Sol-Gel, Bausch Health, and EPI Health. He is an investigator for Sanofi/Regeneron Pharmaceuticals, LEO Pharma, Janssen Pharmaceuticals, Incyte, Vyne Therapeutics, UCB, Pfizer, Eli Lilly and Company, Asana Biosciences, Avillion, AbbVie, Edesa Biotech, Galderma, Dermavant, Arcutis Biotherapeutics, EPI Health, and Concert Pharmaceuticals. He is part owner of AspeticMD.


References:

1. Eichenfield LF, Tom WL, Chamlin SL, et al. Guidelines of care for the management of atopic dermatitis: section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014;70(2):338-351. doi:10.1016/j.jaad.2013.10.01

2. Zirwas M. Practical Approach to Choosing and Using Systemic Therapies for Atopic Dermatitis Based on a Data and Personal Experience. Presented at: New Wave Dermatology Conference; April 28- May 1, 2022; Coral Gables, Florida.

3. Fleming P, Drucker AM. Risk of infection in patients with atopic dermatitis treated with dupilumab: A meta-analysis of randomized controlled trials. J Am Acad Dermatol. 2018;78(1):62-69.e1. doi:10.1016/j.jaad.2017.09.052