October is National Eczema Awareness Month. In a study published in the British Journal of Dermatology in January 2024, the authors found that 2.6% of the world’s population, or 204 million people, have atopic dermatitis (AD). This makes AD a leading cause of skin disease around the world.
To spotlight information on this common skin condition, this article takes a deep dive into atopic dermatitis, highlighting the updated guidelines from the American Academy of Dermatology (AAD).
In This Article: (7 min read⏱️)
🆕 What is Atopic Dermatitis (AD)?
🧑 What are the Causes & Triggers of AD?
🩹 How AD Signs Vary in People of Color
🧑⚕️ What are the AAD’s Updated Treatment Guidelines?
What is Atopic Dermatitis?
Atopic dermatitis (AD) is a chronic, dry and itchy inflammatory skin condition that typically affects the face (cheeks), neck, arms, and legs but usually spares the groin and axillary regions.
Atopic dermatitis is also called atopic eczema, and it is the most common inflammatory skin disease worldwide.
Females are more likely to be affected by AD than males.
Atopic dermatitis is not contagious. This means the condition cannot spread from person to person.
The condition occurs in 10 to 30 percent of children and 2 to 10 percent of adults in the United States.
So, while most people develop atopic dermatitis by 5 years of age, this condition can also start during puberty or later.
The dry and itchy skin can weep clear fluid when scratched which makes people with atopic dermatitis more susceptible to bacterial, viral, and fungal skin infections.
Atopic Eczema is the strongest risk factor for the development of food allergy.
What are the Symptoms of Atopic Dermatitis?
Atopic dermatitis (atopic eczema) is characterized by a range of symptoms that can significantly impact a patient’s quality of life.
Primary symptoms
Intense itching: This is a hallmark symptom of atopic dermatitis and can lead to significant discomfort and sleep disturbance.
Recurrent eczematous lesions: These lesions can present in different clinical phases, including acute (vesicular, weeping, crusting eruption), subacute (dry, scaly, erythematous papules and plaques), and chronic (lichenification, thickening from repeated scratching).
Associated symptoms
Sleep disturbance: The intense itching associated with atopic dermatitis can lead to significant sleep disturbance, which in turn can exacerbate the condition.
Impact on daily activity: The symptoms of atopic dermatitis can significantly impact a patient’s daily activities and overall quality of life.
Comorbid conditions
Rhinitis / rhinoconjunctivitis, asthma, and food allergy: Atopic dermatitis is often associated with other atopic conditions such as rhinitis/rhinoconjunctivitis, asthma, and food allergy 4
How do Clinical Features vary in People with Skin of Color?
There are ethnic variations in patterns of atopic dermatitis. In Māori, Pacific Islanders, and Africans, the papular variant (raised rash) is observed. Perifollicular and extensor, rather than flexural, patterns may also be more common in patients of African descent.
Conventional scoring systems for atopic dermatitis may underestimate the severity of disease and effects on quality of life in those with skin of color due to the erythema appearing violaceous (violet or purple hue). Underestimation may also occur due to cultural factors and communication difficulties between patients, parents, and healthcare providers.
Postinflammatory hypo- and hyper-pigmentation occurs more commonly with skin of color and can be more noticeable than in ethnic white skin, resulting in significant psychological distress.
What are the Causes and Triggers of Atopic Dermatitis?
The exact cause of eczema is not entirely understood. It is believed to be a combination of genetic, immune system, and environmental factors.
Genetic Factors
There is a strong genetic component to eczema, with a family history of eczema, asthma, or allergies commonly found in affected individuals.
Immune-related Genes
Several genes involved in the immune response have also been associated with eczema, including genes that regulate T-cells, cytokines, and immunoglobulins. These genes include interleukin (IL)-4, IL-13, IL-31, signal transducer and activator of transduction (STAT)3, and Fc fragment of immunoglobulin (Ig)E receptor Ig (FCER1G).
Environmental Factors
Environmental factors also play a role in the development of eczema. Patients with eczema have a defect in their skin barrier function, leading to increased water loss and susceptibility to environmental irritants and allergens.
Common triggers for eczema flares include exposure to irritants such as detergents, soaps, solvents, and allergens such as dust mites, pet dander, and certain foods. Other factors that can exacerbate eczema symptoms include stress, changes in temperature and humidity, and infections.
Immune System Activation
In addition to genetic and environmental factors, the immune system is also thought to play a role in the development of eczema. Patients with eczema have an overactive immune response to environmental triggers, leading to inflammation and skin damage.
What’s the Difference between Atopic Dermatitis and Eczema?
Eczema refers to a group of conditions that cause inflamed skin. Signs of inflamed skin include a rash, itchiness, and excessive dryness. There are several types of eczema. Atopic dermatitis is the most common type. Other types of eczema include contact dermatitis and stasis dermatitis.
When talking about atopic dermatitis, many people say “eczema” or “atopic eczema.” They usually call other types of eczema by their specific name. If you’re uncertain when you hear the word “eczema” in a health care setting, ask the person what type of eczema they are talking about.
How is Atopic Eczema Diagnosed?
Atopic dermatitis is usually diagnosed clinically and investigations are not required. Patch testing should be considered, particularly if the dermatitis becomes resistant to treatment [see Guidelines for the diagnosis and assessment of eczema, Atopy patch test, Eczema pathology].
EASI and SCORAD are two scoring systems developed to document the severity of atopic eczema.
How is Atopic Dermatitis Treated?
Agents typically used to treat AD include the following:
- Moisturizers – Petrolatum, Aquaphor, or newer agents such as Atopiclair and Mimyx
- Topical steroids (current mainstay of treatment; commonly used in conjunction with moisturizers) – Hydrocortisone, triamcinolone, or betamethasone; ointment bases are generally preferred, particularly in dry environments
- Broad immunomodulators – Tacrolimus and pimecrolimus (calcineurin inhibitors; generally considered second-line therapy)
- Biologic therapies – Interleukin inhibitors (dupilumab [anti-IL-4Ra], tralokinumab [anti-IL-13], lebrikizumab [anti-IL-13]); Janus kinase (JAK) inhibitors (eg, abrocitinib, upadacitinib, ruxolitinib topical); topical phosphodiesterase-4 (PDE-4) inhibitors (eg, crisaborole topical, roflumilast topical)
Other treatments that have been tried include the following:
- Ultraviolet (UV)-A, UV-B, UV-A plus UV-B, psoralen plus UV-A (PUVA), or UV-B1 (narrow-band UV-B) therapy
- In severe disease, methotrexate, azathioprine, cyclosporine, and mycophenolate mofetil
- Antibiotics for clinical infection caused by S aureus or flares of disease [12]
- Intranasal mupirocin ointment and diluted bleach (sodium hypochlorite) baths
Nonmedical measures that may be helpful include the following:
- Using soft clothing (eg, cotton) next to the skin; wool products should be avoided
- Maintaining mild temperatures, particularly at night
- Using a humidifier (cool mist) in both winter and summer
- Washing clothes in a mild detergent, with no bleach or fabric softener
- Avoiding specific foods as appropriate if there is concomitant food allergy
What are AAD’s Revised Guidelines?
In a 2023 revised guideline, the American Academy of Dermatology (AAD) made the following recommendations on systemic treatments and phototherapy:
The guidelines strongly recommend the use of: dupilumab; tralokinumab; abrocitinib; baricitinib; and upadacitinib.
The guidelines conditionally recommend the use of: phototherapy; azathioprine; cyclosporine; methotrexate; and mycophenolate.
The guidelines recommend against the use of: systemic corticosteroids.
For topical therapy, the guidelines include strong evidence-based recommendations for several treatments, including: moisturizers; topical calcineurin inhibitors; topical corticosteroids; and topical PDE-4 and JAK inhibitors.
Additionally, the guidelines include conditional recommendations for the use of bathing and wet wrap therapy, and recommend against the use of topical antimicrobials, antiseptics, and antihistamines.
What is EBGLYSS and How Does it Work?
In another development, the Food and Drug Administration (FDA) approved Eli Lilly’s EBGLYSS™ (lebrikizumab-lbkz) on September 12 of this year for adults and children aged 12 years and older with moderate-to-severe atopic dermatitis.
EBGLYSS provides a new first-line biologic treatment for moderate-to-severe atopic dermatitis that is not well controlled with topicals.
IL-13 is implicated as a primary cytokine tied to the pathophysiology of AD, and EBGLYSS selectively targets IL-13.
References
- British Journal of Dermatology. A study about how many people around the world have atopic dermatitis. Br J Dermatol. 2024;190(1). https://doi.org/10.1093/bjd/ljad462.
- Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol. 2024;89(1)
- Eli Lilly and Company. EBGLYSS (lebrikizumab-lbkz) prescribing information. Lilly USA, LLC. 2024.
