Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 1

Atopic Dermatitis: A Form of Eczema

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Opening a discussion regarding best practices in managing patients with atopic dermatitis, Douglas DiRuggiero, DMSc, PA-C, describes its relationship to eczema and explains at what age it commonly presents in patients.

Melodie Young, MSN, RN, ANP-C: Hello, and welcome to this HCPLive® Peer Exchange titled “Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives.” I’m Melodie Young. I’m a nurse practitioner at Mindful Dermatology and Modern Research Associates in Dallas, Texas. Joining me today in this discussion are my colleagues Douglas DiRuggiero [DMSc, PA-C], a certified physician assistant at Skin Cancer and Cosmetic Dermatology Center in Rome, Georgia; Keri Holyoak [PA-C, MPH], a certified physician assistant at the Dermatology Center of Salt Lake in Midvale, Utah; and Susan Tofte [DNP, MS, FNP-C], an assistant professor of dermatology and certified nurse practitioner at the Oregon Health and Science University in Portland, Oregon. Our discussion today focuses on understanding atopic dermatitis and the available pharmacological options for the management of this skin disorder. 

Welcome, everyone, let’s get started. First of all, we’re going talk about the pathogenesis prevalence and severity of atopic dermatitis. What is atopic dermatitis, and is the term interchangeable with the word eczema? So, we use eczema and atopic dermatitis together. Douglas, can you speak to that and talk about the age of onset and how patients who have atopic dermatitis present to your clinic?

Douglas DiRuggiero, DMSc, PA-C: Yes. First off, I’m honored to be here with this group. Thank you for this chance to speak. We do know that atopic dermatitis is now considered a specific and separate disease entity underneath the umbrella of eczema. Eczema is a larger umbrella, which includes several types of allergic, irritant, contact, or nummular types of eczema. Atopic dermatitis is now considered a form of eczema that has its own completely different system of pathology and evolution of disease and genetic, phenotypic peculiarities. Even the term atopy means “a-,” to split apart, and “-topy,” meaning topography. These are patients that present with an atypical topography, geography, or landscape to their skin or to their immune system. 

To define atopic dermatitis, we now realize that it’s more than a skin barrier dysfunction. We thought—20 years ago—that if you just fix the barrier, this will all get better. We now know that’s not the case because there’s much more associated with it. It’s a combination of skin barrier dysfunction, of an immune system dysregulation, and of an alteration of the microbiome on the skin—those 3 factors coming together. 

If you look at the skin barrier dysfunction, this is critical. It has to do with some genetic defects with filaggrin mutations and a few other cascades and ceramide problems. The basic premise of that is that patients with atopic dermatitis don’t do a good job of keeping water in and keeping things out. Patients can even have their sweat or chlorine from the pool or shower irritate their skin. It can be a host of air pollutants to contact all these things that can get in earlier, get in faster, and become more irritating. If you just had that, then you have allergic contact dermatitis, irritant dermatitis, and all the other eczemas. But if you combine that with an immune dysregulation or upregulation of Th2 [T helper type 2] cells with this inflammatory cascade that we’ll talk about later in detail—that combination is what creates what we now know as atopic dermatitis. If you had the immune dysregulation by itself, then you would have asthma and allergic rhinitis and those things. Now we know—with mitochondrial RNA [ribonucleic acid] and DNA typing—that this genome, of all those hosts teeming petri dish that lives on our skin of bacteria and diversity of pathogens, is now playing a major role in all these as well. Those 3 things come together to create this entity of atopic dermatitis, which can include asthma and allergies. It can include a severe presentation of eczemalike dermatitis on the skin and can involve a lack of diversity or dysregulation of the microbiome on the skin. 

With kids, 60% present with this and [receive diagnoses] by the age of 2. It moves up to between 75% and 90% by the age of 5. Then 95% [receive diagnoses] by the age of 15. We do have adults that present, which is rare, but it does happen. We’ve all seen it in our clinics. The only caveat is that we do have a particular atopic eruption of pregnancy, AEP, which can present in women in their first trimester [of pregnancy], and only 20% of those women had eczema as a child. We see a higher percentage of new onset when it’s atopic eruption of pregnancy in that certain subset.

Melodie Young, MSN, RN, ANP-C: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchange segments and other great content right in your in-box.

Transcript Edited for Clarity