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Recent Developments in Atopic Dermatitis RecentEric J. Yang, BS, a, b Sahil Developments Sekhon, MD, a Isabelle M. Sanchez, MPH, a, c Kristen in M. Beck, MD, a Tina Bhutani, MDa Atopic Dermatitis abstract ∼ Atopic dermatitis (AD) is a bothersome and common skin disease affecting 10.7% of children in the United States. This skin condition significantly decreases quality of life in not only patients, but in their families as well. Pediatricians are often the first physicians to diagnose and manage these patients and thus are relied on by families to answer questions about this disease. AD is complex, multifactorial, and has historically had limited therapeutic options, but the landscape of this disease is now rapidly changing. Pathways contributing to the pathogenesis of this disease are continually being discovered, and new therapies for AD are being developed at an unprecedented rate. With this article, we will review the current guidelines regarding the management of AD, outline updates in the current aDepartment of Dermatology, University of California, San Francisco, San Francisco, California; bChicago Medical understanding of its pathophysiology, and highlight novel developments School, Rosalind Franklin University of Medicine and available for the treatment of this burdensome disease. Science, North Chicago, Illinois; and cCollege of Medicine, University of Illinois at Chicago, Chicago, Illinois Mr Yang, Dr Sekhon, Ms Sanchez, and Drs Beck and Atopic dermatitis (AD) is a chronic of AD is responsible for its significant Bhutani participated in the drafting and revising ∼ inflammatory skin disease that affects negative impact on quality of life of this manuscript; and all authors approved the 8 final manuscript as submitted and agree to be 10.7% of children in the United (QoL). Patients with AD often present 1 – accountable for all aspects of the work. States and is becoming increasingly with severe pruritus and xerosis, with 2 4 DOI: https:// doi. org/ 10. 1542/ peds. 2018- 1102 prevalent. Pediatricians are variable lesion distribution based on often the first physicians providing age. Young infants up to 2 years of Accepted for publication Jul 24, 2018 ∼ Address correspondence to Eric J. Yang, BS, treatment to patients with5 new-onset age often present with scaly, crusted AD and disease flares, and 50% erythematous patches on the scalp, Department of Dermatology, University of California, San Francisco, 515 Spruce St, San Francisco, CA of patients with AD are treated in face, and extensor surfaces, whereas 6 94118. E-mail: [email protected] a primary care setting. Therefore, prepubertal children present with PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, pediatricians play a key role in the erythematous patches in a flexural 9 1098-4275). overall management of patients with distribution. Adolescents and adults Copyright 2018 by the American Academy of AD and should be well informed about typically present with more lichenified © Pediatrics recent developments in the clinical skin changes. 7 FINANCIAL DISCLOSURE: Dr Bhutani is an management of this disease. The progression of AD is investigator for AbbVie, Janssen, Merck, Eli Lilly, Despite its high prevalence, this unpredictable, but the following and Strata Skin Sciences but has no direct financial complex disease has historically been 4 phenotypes have recently been conflicts to report; the other authors have indicated they have no financial relationships relevant to this poorly understood. With this article, we identified: early-onset transient (9.2% article to disclose. provide an update on recent advances of children), early-onset persistent FUNDING: No external funding. in our understanding of the clinical (6.5%), late-onset (4.8%), 10and absent presentation and pathophysiology or infrequent AD (79.5%). Patients POTENTIAL CONFLICT OF INTEREST: Dr Bhutani is an investigator for AbbVie, Janssen, Merck, Eli Lilly, of AD and highlight new therapeutic with AD have alternating periods of and Strata Skin Sciences; the other authors have developments for this disease. exacerbated disease and symptom indicated they have no potential conflicts of interest CLINICAL COURSE resolution. Thus, both the alleviation of to disclose. symptoms and prevention of flares are importantDiagnosis in the management of AD. “ ” To cite: Yang EJ, Sekhon S, Sanchez IM, et al. AD is a bothersome skin condition often Recent Developments in Atopic Dermatitis. Pedi- referred to as the itch that rashes atrics. 2018;142(4):e20181102 because of the pruritus that patients Patients commonly present during experience. This hallmark symptom acute flares with intense pruritus, Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 142, number 4, October 2018:e20181102 STATE-OF-THE-ART REVIEW ARTICLE xerosis, erosions, excoriations, and which contribute to an increased sleep, social functioning, work ill-defined patches of erythema with7, 11 susceptibility of21, developing22 productivity, and income. a distribution that varies with age. skin infections. Because AD has a well-characterized negative AD is clinically diagnosed on the basis of a decreased antimicrobial 40, 41 23 impact on sleep in children of history, morphology, distribution peptide expression, >75% of 42 Staphylococcus aureus and their families because of of skin lesions, and associated clinical affected children are colonized by 11 debilitating pruritus and the signs. Other important factors , compared Staphylococcus constant care needed for this disease. suggesting a diagnosis of AD include with <25% of healthy children in 24 Children with moderate-to-severe early onset (<2 years of age), atopy, control groups. 11, 12 AD experience more restless sleep, and family history of disease. colonization worsens inflammation 24 increased waking, greater difficulty This diagnosis should be reevaluated and pruritus, increasing the risk of Streptococcus pyogenes falling asleep, and increased daytime frequently, particularly in patients colonization and/or superinfection sleepiness compared with healthy not responding to appropriate with , 21 patients; these are behaviors that treatment, to verify the accuracy viruses, or fungi. AD can also worsen with the severity of AD and of this diagnosis and exclude the predispose patients to disseminated 21, 43 with flares. Parents of affected possibility of other conditions, eczema herpeticum and molluscum ∼ – 21 children also experience significant such as scabies, contact dermatitis, contagiosum outbreaks. sleep loss ( 1 3 hours per night) psoriasis, tinea infections, or viral 7, 13 Currently well-known comorbidities while providing overnight care to Comorbiditiesexanthems. and Complications of AD are mostly atopic, but AD soothe their children42,44 and help them “ ” may have a broader impact on return to sleep. The severity of health. Authors of recent studies sleep disruption associated with AD AD is thought to kick off the have shown that patients25, with26 AD is comparable to that of other chronic atopic march, predisposing patients are more likely be obese and conditions requiring constant care, to other atopic disorders later 14, 15 have elevated serum cardiovascular27 including autism spectrum disorder, in life. Patients with AD with risk markers than healthy patients,– mental retardation,45 and seizure early sensitization to foods have an contributing to increased 28 30 disorders. An effective treatment increased risk of developing asthma,16 cardiovascular disease risk. plan is necessary to minimize the allergic rhinitis, and food allergies. However, severe AD in children and QoL impairment because of poor46 Therefore, early diagnosis and adolescents– has also been associated sleep in both affected47 patients management of AD and its associated with impaired31 34 growth and short and their families. risk factors may reduce the risk of stature. Patients with AD are also AD affects children during critical developing other allergic 16diseases at an increased risk of developing stages of childhood development, and improve overall QoL. depression, anxiety, attention-deficit/ – causing significant QoL impairment hyperactivity disorder, and conduct AD has been associated with an 35 37 at ages when patients are most disorder, with risk correlated increased risk of developing17 a peanut 35 vulnerable. Children with AD can with AD disease severity. AD is allergy specifically, but previous be severely impacted by fear of not just skin deep, and management 46, 48 clinical practice guidelines on food embarrassment and constant should be used to address the 49 allergy prevention were constantly anxiety about future flares. Patients comorbidities, in addition to skin changing. Most recently, the Learning with AD are often socially isolated symptoms, associated with this Early About Peanut Allergy trial and bullied because of the fear of systemic disease. 50 revealed that an early introduction of QoL Impairments contagion and stigma, leading to peanut-containing foods reduces the poor self-esteem in these young51 risk of developing a peanut allergy and impressionable patients. As in high-risk patients, including18 Although skin disease is often a result, patients with AD often infants with severe AD. Current perceived to be relatively benign, withdraw socially, avoid group consensus guidelines recommend an children with generalized AD activities, or may even skip school46, 52to introduction of peanut-containing report QoL deficits similar to that of prevent further embarrassment. foods such as peanut butter
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