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Management of Type 2 Inflammation in Atopic Dermatitis - Episode 13

Challenges in Treating AD: Heterogeneity of Disease

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Marc Serota, MD, elucidates the heterogeneity of atopic dermatitis and explains how this can contribute to challenges in treating patients.


Marc Serota, MD: One of the most common questions I get from my colleagues when I speak about atopic dermatitis is [about] diagnosing and managing difficult cases. I think the first point to be made is that people with dermatitis are a very heterogeneous group, and atopic dermatitis within dermatitis is also a very heterogeneous group, where every patient presents a little differently.

I always say I care much more that you know you’re in the pathway of dermatitis than I care that you can fit it in the classic textbook description of atopic dermatitis because the description of atopic dermatitis is just that—it’s a clinical description. It’s not necessarily based on the immunology or pathophysiology of what’s going on, on a more microscopic level of the skin. If you know you’re in the dermatitis pathway, to me that is more important than being able to subcategorize the dermatitis.

I think it’s important to look for confounding factors, like allergic contact, or just complete mimics of their disease. I’ve seen scabies missed as atopic dermatitis. I’ve seen CTCL [cutaneous T-cell lymphoma] missed as atopic dermatitis; allergic contact, certainly, and various other inflammatory diseases. There’s a notorious diagnosis in the world of dermatology called psoriasiform dermatitis, where you can’t tell if it’s psoriasis or atopic dermatitis, so then you biopsy it and then the biopsy comes back psoriasiform dermatitis. Basically, the pathologist is telling you that they can’t really tell either under the microscope.

One pearl when I see patients like this, I try to use the history to help me. Do they have a history of other atopic conditions? But also, sometimes I’ll do what I call a diagnostic therapeutic trial, where if I think it’s dermatitis, and let’s say they have some background asthma as well, for example, I will treat them and block that pathway with something like dupilumab, and then reassess them at 12 weeks or 16 weeks and see how we did. If we made no improvement at all, then I think maybe we’re in the other pathway. If they cleared nicely, then I’m confident in saying that by blocking that pathway, I treated their dermatitis.

I think in the future, we may categorize these things more by the immunology that’s happening in the skin as opposed to a clinical description of what you’re seeing visually. But I think using some of the histories to help you and some of, not just what worked to treat them, but almost as importantly, what doesn’t work to treat them, can help you when you’re trying to discern some of these more difficult cases.

Transcript edited for clarity.