Practical Strategies for the Diagnosis and Assessment of Atopic Dermatitis
Atopic dermatitis (AD) has a significant, lifelong clinical impact on affected individuals and has profound effects on quality of life both for patients and their families. The diagnosis usually can be reliably established on the basis of the history and physical examination. In patients with skin of color, blanching of the skin may be helpful to detect erythema, lichenification, follicular accentuation, and hypopigmentation (all of which are more common than in lighter-skinned patients). Once the diagnosis of AD is established, an assessment of severity, persistence, and impact on the patient’s and family’s life is important as a guide to treatment decisions. Semin Cutan Med Surg 36(supp2):S36-S38 © 2017 published by Frontline Medical Communications
Atopic dermatitis; eczema
The prevalence of atopic dermatitis (AD) in the United States is about 3% to 5% in the overall population, or approximately 15 million children and adults. The current lifetime prevalence of AD in childhood is estimated to be 10% to 15%, which is an increase of 6% to 10% over the last 30 years.1-5
In addition, AD prevalence among children differs according to geography. In the United States, prevalence varies markedly by region, from a low of 8.7% in Florida to a high of 18.05% in Maryland.6 These differences may be the result of environmental and other factors such as sun exposure, baseline humidity, and urban/rural gradients.7
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Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time. The online post-test and evaluation can be accessed at http://tinyurl.com/meetingthechallengeofatopic. Inquiries about CME accreditation may be directed to the University of Louisville Office of Continuing Medical Education & Professional Development (CME & PD) at firstname.lastname@example.org or (502) 852-5329.
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The diagnosis of atopic dermatitis can be challenging because the type and appearance of skin lesions can vary and some common cutaneous conditions—such as seborrheic dermatitis (“cradle cap”) in infants—may coexist. In most cases, attention to characteristic features of AD leads to the correct diagnosis. Awareness of clinical circumstances that should lead to consideration of some rare conditions in the differential diagnosis also is important.
Recently published studies that have furthered the understanding of the role of filaggrin, filaggrin gene mutations, and transepidermal water loss have demonstrated that daily, full-body emollient applications, beginning at birth, may prevent the expression of AD in susceptible children. For all patients with AD, the use of adequate skin hydration combined with the prompt application of ointment or cream moisturizers (“soak and seal”) remains the cornerstone of AD therapy.
Recent advances in understanding the complex pathophysiology of AD have led to the development of new and emerging topical and systemic medications that may effectively manage the signs and symptoms of AD in patients who do not respond adequately to standard treatment regimens. These include the topical phosphodiesterase-4 inhibitor crisaborole, recently approved for use in AD by the US Food and Drug Administration (FDA), and the subcutaneously administered interleukin-4 receptor α subunit inhibitor dupilumab, for which phase III pivotal study data are now available.
Clinicians must remain up-to-date on the findings from clinical studies on the diagnosis and management of AD, as well as the benefits and risks of all treatment options available, to make the appropriate choices for management of their individual patients.
By reading and studying this supplement, participants should be better able to:
- Discuss the features of AD that should allow a clinical diagnosis of the condition in most patients, and list the factors in children and adults that should lead to the consideration of alternative diagnoses or identification of comorbid conditions.
- Explain how the current understanding of the role of the epidermal skin barrier and transepidermal water loss should affect—and continue to improve— the day-to-day care of patients with AD.
- More effectively individualize patient treatment strategies by considering the full range of current and emerging therapeutic options.
- Consider the evidence-based recommendations in the current guidelines for the diagnosis and treatment of AD published by the American Academy of Dermatology.
- Describe the rationales and mechanisms of action of the new and emerging therapies for AD, particularly the recently approved topical agent crisaborole and the systemic medication dupilumab (phase III study results under FDA review at the time of publication of this supplement).
Individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of non-profit or government organizations and non-health care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Lawrence F. Eichenfield, MD, Advisory Board/Speaker: Valeant Pharmaceuticals North America LLC. Consultant: Anacor Pharmaceuticals, Inc./Pfizer Inc., Eli Lilly and Company, Genentech, Inc., Otsuka America Pharmaceutical, Inc./Medimetriks Pharmaceuticals, Inc., Sanofi Genzyme/Regeneron Pharmaceuticals, TopMD, Valeant. Investigator: Sanofi Genzyme/Regeneron.
Linda F. Stein Gold, MD, Consultant: Anacor. Grant/Research: Anacor, GlaxoSmithKline. Data Monitoring Committee: Otsuka.
Staff and Advisory Board Disclosures: The CME & PD staff pediatricians, family practitioners, and Advisory Board have nothing to disclose.
CME/CE Reviewers: Cindy England Owen, MD, Assistant Professor, Division of Dermatology, University of Louisville School of Medicine, has no relevant financial relationships to disclose. The PIM planners and managers, Trace Hutchison, PharmD; Samantha Mattiucci, PharmD, CHCP; Judi Smelker- Mitchek, MBA, MSN, RN; and Jan Schultz, MSN, RN, CHCP, have nothing to disclose.
Global Academy for Medical Education Staff: Sylvia H. Reitman, MBA, DipEd; Jenny Campano; Tristan Nelsen, MNM, CMP, HMCC; and Joanne Still have no relevant financial relationships to disclose.
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This CME/CE activity discusses the off-label use of certain approved medications as well as data from clinical trials on investigational agents. Any such material is identified within the text of the articles.
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1. Eyerich K, Novak N. Immunology of atopic eczema: Overcoming the Th1/Th2 paradigm. Allergy. 2013;68:974-982. http://www.cdc.gov/media/ releases/2016/p0504-hepc-mortality.html. Published May 4, 2016. Accessed December 9, 2016.
2. Leung DY, Bieber T. Atopic dermatitis. Lancet. 2003;361:151-160.
3. Blumberg SJ, Olson L, Frankel M, Osborn L, Srinath KP, Giambo P. Design and operation of the National Survey of Children’s Health 2003 (NSCH). Vital Health Stat 1. 2005;(43):1-124. [National Survey of Children’s Health (NSCH), 2003 www. childhealthdata.org].
4. Simpson EL, Hanifin JM. Atopic dermatitis. Med Clin North Am. 2006;90:149-167.
5. Ozkaya E. Adult-onset atopic dermatitis. J Am Acad Dermatol. 2005;52:579-582.
6. Shaw TE, Currie GP, Koudelka CW, Simpson EL. Eczema prevalence in the United States: Data from the 2003 National Survey of Children’s Health. J Invest Dermatol. 2011;131:67-73.
7. Kathuria P, Silverberg JI. Association of pollution and climate with atopic eczema in US children. Pediatr Allergy Immunol 2016;27:478-485.
8. Siegfried EC, Hebert AA. Diagnosis of atopic dermatitis: Mimics, overlaps, and complications. J Clin Med. 2015;4:884-917.
9. Weidinger S, Novak N. Atopic dermatitis. Lancet. 2016;387:1109-1122.
10. 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;70:338-351.
11. Spergel JM, Boguniewicz M, Schneider L, Hanifin JM, Paller AS, Eichenfield LF. Food allergy in infants with atopic dermatitis: Limitations of food-specific IgE measurements. Pediatrics. 2015;136.
12. Du Toit G, Roberts G, Sayre PH, et al. Learning Early About Peanut Allergy (LEAP) Study Team. Identifying infants at high risk of peanut allergy: The Learning Early About Peanut Allergy (LEAP) screening study. J Allergy Clin Immunol. 2013;131:135-143.
This continuing medical education (CME/CE) supplement was developed from a satellite symposium held at the Skin Disease Education Foundation’s 17th Annual Las Vegas Dermatology Seminar, November 11, 2016, in Las Vegas, Nevada. The Guest Editors acknowledge the editorial assistance of Global Academy for Medical Education and Joanne Still, medical writer, in the development of this supplement. The manuscript was reviewed and approved by the Guest Editors as well as the Editors of Seminars in Cutaneous Medicine and Surgery. The ideas and opinions expressed in this supplement are those of the Guest Editors and do not necessarily reflect the views of the supporter, Global Academy for Medical Education, the University of Louisville, Postgraduate Institute for Medicine, or the Publisher.
* Chief, Pediatric and Adolescent Dermatology, Professor of Dermatology and Pediatrics, Rady Children’s Hospital, University of California, San Diego School of Medicine, San Diego, California
† Director of Dermatology Research, Henry Ford Health System, Detroit, Michigan
Publication of this CME/CE article was jointly provided by University of Louisville, Postgraduate Institute for Medicine, and Global Academy for Medical Education, LLC, and is supported by an educational grant from Anacor Pharmaceuticals, Inc. The authors have received an honorarium for their participation in this activity. They acknowledge the editorial assistance of Joanne Still, medical writer, and Global Academy for Medical Education in the development of this continuing medical education journal article.
Lawrence F. Eichenfield, MD, Advisory Board/Speaker: Valeant Pharmaceuticals North America LLC. Consultant: Anacor/Pfizer Inc., Eli Lilly and Company, Genentech, Inc., Otsuka America Pharmaceutical, Inc./Medimetriks Pharmaceuticals, Inc., Sanofi Genzyme/Regeneron Pharmaceuticals, TopMD, Valeant. Investigator: Sanofi Genzyme/Regeneron.
Linda F. Stein Gold, MD, Consultant: Anacor. Grant/Research: Anacor, GlaxoSmithKline. Data Monitoring Committee: Otsuka.
Address reprint requests to: Lawrence F. Eichenfield, MD, Rady Children’s Hospital, 8010 Frost Street, Suite 602, San Diego, CA 92123; firstname.lastname@example.org
© 2017 Frontline Medical Communications 1085-5629/13/$-see front matter doi:10.12788/j.sder.2017.009