Maureen Salamon

July 30, 2017

NEW YORK CITY — Atopic dermatitis may be more prevalent in adults than previously realized, in part because it is a difficult diagnosis to make.

"Adult-onset atopic dermatitis is a controversial topic," said Jonathan Silverberg, MD, PhD, from the Northwestern University Feinberg School of Medicine in Chicago, Illinois.

"Some believe it's adult recurrence, that the patient had it as a child but was undiagnosed," he reported here at the American Academy of Dermatology (AAD) 2017 Summer Meeting.

"From a clinical standpoint, my gestalt is, who cares?" he added. "That shouldn't scare you about making the diagnosis."

Citing National Health Interview Survey data showing that between 7% and 10% of adults in the United States suffer from atopic dermatitis, which is about half the number of children affected, Dr Silverberg said the condition is still surrounded by misinformation, hampering attempts to correctly diagnose it.

It's totally screwing up our ability to look at big population-based data. Dr Jonathan Silverberg

Atopic dermatitis is often referred to as eczema by lay people and by healthcare professionals, but the term is too imprecise, he said.

"The problem, from a clinical standpoint, is that the term eczema means something different to different practitioners," he explained. "And it has a different ICD code than atopic dermatitis. It's totally screwing up our ability to look at big population-based data."

Data from a previous study showed that patients who, as children, developed atopic dermatitis that persisted into adulthood exhibit null mutations in the filaggrin gene, but that these mutations are not associated with those whose dermatitis began in late childhood or adulthood, said Dr Silverberg ( Br J Dermatol. 2015;172:455-461).

"This suggests that the genetics may be entirely different. To me, this is an exciting subset of patients," he said.

Adults presenting with atopic dermatitis also tend to be affected more on the head, neck, and hands than children, whose disease often manifests as a flexural distribution.

"A 6-month-old with an atopic diagnosis is kind of a no-brainer," he said. "But it's not an easy diagnosis to make in adults." It requires ruling out disorders such as psoriasis, scabies, contact or drug-induced dermatitis, and cutaneous T-cell lymphoma, he explained. No biomarkers or blood tests have emerged to simplify the process.

Sleep disturbance in adults with severe atopic dermatitis is pervasive, he added, with those who suffer about 11 flares per year also having to cope with an average of 192 nights of sleep disruption. Other common atopic dermatitis comorbidities such as depression, cardiovascular disease, and obesity can also be intricately tied to lost sleep, he said.

"Sleep may be arguably one of the most important predictors of quality of life," said Dr Silverberg. "If for 192 nights of the year you're not sleeping, it really messes with your head and with your burden of mental disease."

If we lived in a utopian society where cost didn't matter, I would argue dupilumab should be used for all patients with chronic moderate-to-severe atopic dermatitis. Dr Jonathan Silverberg

The recent approval by the US Food and Drug Administration of the monoclonal antibody dupilumab (Dupixent, Sanofi/Regeneron), the first human biologic therapy available for moderate to severe atopic dermatitis, is an exciting option for adult patients for whom other systemic agents have fallen short, said Dr Silverberg.

Dupilumab has significantly benefited the vast majority of his patients, despite the drug's potential adverse effects, which include conjunctivitis and other eye symptoms, he reported.

"Almost none of the patients going on this drug are going to stop just because of conjunctivitis," he added.

"If we lived in a utopian society where cost didn't matter, I would argue dupilumab should be used for all patients with chronic moderate to severe atopic dermatitis," he said.

"It's been said that the last decade was the best for psoriasis, and I would say now is the best time for atopic dermatitis."

Asked to comment on the presentation, Christine Neagoe, MD, a dermatologist at Dr V Medical & Cosmetic Dermatology Clinic in Ontario, Canada, said she had been curious about the differences between childhood and adult-onset atopic dermatitis.

"My diagnostic clarification will be improved in terms of trying to determine atopic dermatitis vs an allergy," she told Medscape Medical News.

"I also may do a little more counseling with patients in terms of sleep and lifestyle," she added.

Dr Silverberg is a speaker for Regeneron/Sanofi; a consultant for AbbVie, Anacor, Eli Lilly, Galderma, GlaxoSmithKline, Kiniksa, Leo, Medimmune-Astra Zeneca, Menlo, Pfizer, Realm, Regeneron/Sanofi, and Roivant; and an investigator for AbbVie, Celgene, Chugai, Galderma, GlaxoSmithKline, Eli Lilly, Realm, Roche-Hoffman, and Regeneron/Sanofi. Dr Neagoe has disclosed no relevant financial relationships.

American Academy of Dermatology (AAD) 2017 Summer Meeting.

Follow Medscape Dermatology  on Twitter @MedscapeAllergy and Maureen Salamon maureensalamon

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