Written by Sonya G. Zarkhin, DO
Edited by Paul M. Graham, DO
For years, patients and their families have gone into their dermatologist’s office for their itchy skin and left with a diagnosis of “eczema”, or atopic dermatitis. Unfortunately for many, getting the correct diagnosis was a complete breeze compared to understanding the root cause of their disorder and most importantly how to minimize their symptoms and outbreaks. In this installment, we’ll dive into understanding atopic dermatitis, its management, and finally the exciting new drugs that may give relief to those suffering from this often mysterious disease.
Who’s got the itch?
Atopic dermatitis, or AD, is an inflammatory skin condition that can be seen in both children and adults alike. In fact, its one of the most common inflammatory skin conditions!(1) Infants will typically present with this condition within the first year of life and half of these cases will resolve by 18 months.(2) Children and adults may present at any age. It is speculated that anywhere from 10-25% children have AD while only 2-10% of adults are affected.(3) Those with atopic dermatitis may also suffer from asthma and allergy, or allergic rhinitis. These conditions are all associated with high levels of IgE, an antibody that is responsible for the allergic response. Together these three (atopic dermatitis, asthma, and allergy) constitute a triad of atopic conditions commonly seen in patients.(4)
What’s to blame?
AD is caused by an epidermal skin barrier dysfunction.(5) Our skin is the biggest and most important barrier protecting us from harsh environmental conditions, so it’s no surprise our skin lets us know when this important barrier is disrupted (although many could agree the skin could do so in a more comfortable way and not through itchiness and rashes!) Cracks or alterations in the stratum corneum (top layer of the skin) allow irritants into our skin as well as allowing water to flow out of the skin.(5) Special proteins called fillagrin are vitally important to maintaining the skin’s integrity. Mutations in the fillagrin gene, as seen in AD, cause disruptions in the epidermis and ultimately the rash and itch from irritation and dryness.(5)
In addition to genetics and irregularities in the skin barrier, some studies have also shown certain foods to trigger a flare of AD as well. For example, foods that are high in nickel have shown to have an effect on AD. These foods include: whole wheat, oatmeal, beans, lentils, peas, soybeans, and shellfish.(6)
Tips and Tricks
While it may be difficult to monitor nickel intake, and you certainly can’t change your genetics, here’s a few tricks that may help avoid an AD flare. Maintaining the integrity of the skin barrier is very important as it is easier for AD patients to lose hydration/water through the skin. These techniques help the skin maintain its moisture.(7)
- Avoiding scalding hot showers or baths
- Avoiding bubble baths
- Patting the skin dry, not rubbing or scrubbing
- Moisturizing immediately after bathing
New Kids on the Block
After many years, there are finally new products and medications on the market aimed to help those with AD. Many in the AD community are excited about these breakthroughs and that AD is finally getting the attention it deserves!
Dupilumab, commercially known as Dupixent, is an injectable medication approved for people with moderate to severe AD.(8) It is a biologic medication that serves as a monoclonal antibody that inhibits IL-4 and IL-13.(9) What this means is that this molecule blocks the binding of IL-4 and IL-13 (signaling molecules) to their cell receptor, thus decreasing the cell signal and the downstream effects of this binding. If uninhibited, IL-4 and IL-13 are responsible for the release of pro-inflammatory signaling molecules (cytokines, chemokines, and IgE) which are all implicated in the inflammatory response seen in AD.(9) By blocking the release of these inflammatory signals, Dupilumab helps decrease the appearance and symptoms of AD. At this time Dupilumab is only FDA-approved for those 18 years old or older but the company is diligently working on approval for minors and children as well.(8)
Crisaborole, commercially known as Eucrisa is a topical ointment approved for mild to moderate AD.(10) Eucrisa is applied to the affected skin twice a day and is a PDE-4 inhibitor. At this time, it is not understood how the inhibition of PDE-4 alleviates the symptoms of AD.(10) Crisaborole can be used in children as it has been approved for anyone 2 years-old or older.(10) A potential side effect of Crisaborole is a mild burning at the application site. However, this side effect decreases with continued use.(10)
Ultimately, while many have AD or AD-like conditions, presently there are few pharmacological tools to help these patients. Thankfully, as our understanding of this condition continues to become more robust, more treatments targeting specific pathological mechanisms will continue to emerge and follow in Crisaborole and Dupilumab’s footsteps. Until then, maintaining a healthy skin barrier and minimizing moisture loss from the epidermis is vitally important.
If you or someone close to you suffers from atopic dermatitis or eczema, make sure to schedule a visit with your dermatologist for a comprehensive evaluation and treatment plan.
Don’t forget to check out our other articles on eczema here: Should I Supplement My Child with Probiotics? and Itching for Relief: Dry Skin Care
- “Atopic dermatitis.” Atopic dermatitis | American Academy of Dermatology. Accessed May 2017. https://www.aad.org/public/diseases/eczema/atopic-dermatitis.
- Habif, T. “Atopic Dermatitis .” In Clinical Dermatology, 150-77. 6th ed. Elsevier Inc, 2016.
- Bolognia, J., J. Schaffer, K. Duncan, and C. Ko. “Atopic Dermatitis .” In Dermatology Essentials, 92-102. Elseveir Inc, 2014.
- “Asthma Allergic Rhinitis and Dermatitis.” National Eczema Association. Accessed May 2017. https://nationaleczema.org/atopic-dermatitis-in-children/atopic-triad/.
- Cork, M. J., S. Danby, Y. Vasilopoulos, M. Moustafa, A. Macgowan, J. Varghese, G. W. Duff, R. Tazi-Ahnini, and S. J. Ward. “Epidermal barrier dysfunction in atopic dermatitis.”Series in Dermatological Treatment Textbook of Atopic Dermatitis, 2008, 35-58. doi:10.3109/9780203091449.004.
- Katta, R., and M. Schlichte. “Diet and Dermatitis: Food Triggers.”The Journal of Clinical and Aesthetic Dermatology7, no. 3 (March 2014): 30-36.
- “Skin Care Tips for Individuals with Atopic Dermatitis | AAAAI.” The American Academy of Allergy, Asthma & Immunology. Accessed May 23, 2017. https://www.aaaai.org/conditions-and-treatments/library/allergy-library/skin-care-tips-atopic-dermatits.
- “Now Available: DUPIXENT®(dupilumab).” Home. Accessed May 2017. https://www.dupixent.com/.
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