Clinical Presentation of Atopic Dermatitis
Raj J. Chovatiya, MD, PhD, reviews the clinical manifestations and underdiagnoses of atopic dermatitis.
Raj J. Chovatiya, MD, PhD: You touched on a couple of facts. I’ll review and say with atopic dermatitis, it’s clinical manifestations. We heard about what was happening with Taylor and Tina. There’s a lot of confusion, atopic dermatitis, eczema, dermatitis, atopic eczema. What’s going on here? This is historically related to nomenclature in the literature in terms of what’s going on. The big thing to think about is atopic dermatitis, or sometimes called atopic eczema, is one of the most common types of eczema. Eczema itself being a family of rashes that share certain characteristics in terms of scaling and redness. Sometimes chronic recurrence, itchiness. But there’s other types of eczema—contact dermatitis, nummular discoid eczema, etc. But atopic dermatitis you can think about as a chronic relapsing, readmitting inflammatory disease. When does atopic dermatitis start? We heard about childhood. It’s not always. People can have atopic dermatitis starting any points in life. Most commonly, we’re usually thinking about the first few years of life and then you’re wondering then if that happens, do people outgrow it? Do people not outgrow it? The historical idea was eczema is this thing you get in childhood. It goes away. It’s not that big of a deal and research over the last 10 years has shown that that is definitely not the case. There are several good longitudinal studies that have showed that potentially a majority of eczema might persist at some point to beyond adolescence into the rest of life. There’s others that have said, maybe this rate’s a bit lower. It’s harder to study because of the length of time required and defining these ideas of what’s persistence and what’s recurrent. The bottom line to think about is because you have atopic dermatitis at one point in your life, it very well may be something that’s with you on and off throughout your entire life. For that reason alone, it’s a huge burden to think about. In terms of overall prevalence, it’s common. In this country, about 7% of adults and 13% of children at any given time have atopic dermatitis and with numbers like that, it’s huge. Diagnosis is probably even underdiagnosed. People may get told that you have a little of irritation on your skin. It’s not a big deal. There’s even increased difficulty for diagnosis based on skin type. Individuals with darker or richly pigmented skin, may not have eczema present the same exact way as somebody with lighter skin so this leads to misdiagnosis, misclassification, and underrating of severity. Even though mild disease is the most common form, there is a lot more moderate and severe disease out there that we’re not seeing or hasn’t been appropriately diagnosed. Without getting esoteric about it, when we think about the pathophysiology of atopic dermatitis, you can think of, largely, a couple important things. There’s dysregulation of the immune system, especially in the skin. There’s barrier issues in the skin. And so, most of our therapies are addressed trying to fix both of those things. When I say barrier issues, the skin is leakier, it loses water. That’s one of the reasons why things get so dry. Outside toxins and allergens can irritate the skin. And in the case of the immune system, it’s overactive. That’s why you get these itchy, red, scaly rash, thickened areas. That’s how our treatment works.
Transcript Edited for Clarity
