An Overview of Atopic Dermatitis (AD)


Peter A. Lio, MD, provides an overview of the pathophysiology of atopic dermatitis (AD) and the comorbidities often associated with it.

Linda Stein Gold, MD: Hello, and welcome to this HCPLive® Peer Exchange titled “Improving Quality of Life in Atopic Dermatitis With Targeted Therapies.” My name is Dr Linda Stein Gold, and I’m the director of dermatology clinical research at Henry Ford Health in Detroit, Michigan. Joining me are my friends, colleagues, and atopic dermatitis [AD] enthusiasts. Matt?

Matthew Zirwas, MD: I’m Dr. Matthew Zirwas from Columbus, Ohio. I practice at DOCS Dermatology, and I run a clinical trial center.

Peter Lio, MD: I’m Peter Lio, and I’m a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

Alexandra K. Golant, MD: I’m Alexandra Golant, and I’m a dermatologist in New York City, practicing at the Icahn School of Medicine at Mount Sinai.

Aaron Farberg, MD: I’m Aaron Farberg, a board-certified dermatologist and the chief medical officer at Bare Dermatology in Dallas, Texas.

Linda Stein Gold, MD: Our discussion will focus on how new and advanced treatments are impacting the quality of life of individuals with atopic dermatitis. We’ll also explore how we can optimize the patient experience by utilizing these therapies in a strategic manner. Welcome, and let’s get started.

Atopic dermatitis is a chronic inflammatory skin disease, and it has a major impact on patients’ overall quality of life. This disease is more than just skin deep. Let’s start by briefly going over the pathophysiology of the disease and talk a little about the comorbidities. Peter, start by giving us an overview of what’s going on with this disease.

Peter Lio, MD: Thank you. It’s a complex and heterogeneous disease, and it isn’t the same for every patient, but there are some pathogenic factors that everybody has involved no matter where you begin. I break them down into a skin barrier problem. We know you have this leaky skin: you’re losing water and also allowing for allergens, irritants, pollutants, and pathogens to get into the skin. There’s a problem with inflammation. There’s too much inflammation, in particular the type 2 inflammatory pathway that’s raging in the skin. There’s itch, and that piece is important because that drives the next part: the scratching behavior, which not only fuels inflammation but damages the skin barrier. Finally, we have the concept of the microbiome, and that’s disrupted by all these barrier and inflammation changes. All these things come together to create this disease. We don’t fully understand the predisposing factors, but there are certain genes involved. Filaggrin is 1 that has a very high rate of being associated with atopic dermatitis. All these come together in patients, and there are probably environmental pieces that fuel it as well.

Linda Stein Gold, MD: Peter, we understand this has a complex pathophysiology. We understand that the skin is involved, but there are comorbidities. Can you talk a little about that?

Peter Lio, MD: Unfortunately, we often get bonuses along with atopic dermatitis, both allergic and nonallergic, not that we want them. Allergic comorbidities include things like asthma, food allergy, and allergic rhinitis. These are very common, and sometimes they come in a progression that can be referred to as the atopic march. But we also have a whole host of nonallergic comorbidities, and this is where it gets interesting. With patients who have mental health issues, like depression and anxiety, and even some things further afield there’s a higher rate of infection. All sorts of ramifications can happen. Part of it is that it becomes difficult to disentangle from some other issues, like sleep issues. A lot of these patients, particularly those who are more moderate or severe, have sleep problems. That can lead to a whole host of problems.

Linda Stein Gold, MD: Thanks. We understand this is so all encompassing. These patients are itchy and sleep deprived. Can you give us a little insight into how this affects the overall quality of life?

Alexandra Golant, MD: When you look at quality of life impact in atopic dermatitis, the impact on sleep is a huge driver of the suffering. Often, when you’re dealing with a disease that begins in childhood, not only is the child’s quality of life impacted, but…when a child doesn’t sleep, the impact isn’t confined to that child. You have impact on parental health, work performance, and work attendance. When a child doesn’t sleep, there have been multiple studies looking at that impact overall, in terms of not just school performance but also growth effects, psychosocial effects on how that child comes to see themselves in the world, and future risk for psychiatric disease, depression, and anxiety.

Interestingly, the way we regard atopic dermatitis in relation to quality of life has also changed. In our understanding of AD as a systemic disease, we’re gaining a greater appreciation of the holistic effect this has on the patient. If you look at early studies trying to compare atopic dermatitis and its impact on quality of life with other chronic childhood diseases, it’s at the level of things like type 1 diabetes and systemic diseases that can affect all areas of a patient’s life. Paramount to that conversation in the exam room with patients or parents is asking, “How is this impacting you day to day? How much time are you spending taking care or worrying about your child’s skin disease and their overall health?” Those conversations help inform you as you’re approaching treatment decisions in the office as well.

Transcript edited for clarity

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