Update on Atopic Dermatitis: Diagnosis, Severity Assessment, and Treatment Selection

Abstract

Atopic dermatitis (AD) is one of the most common inflammatory skin diseases affecting children and adults. The intense pruritus and rash can be debilitating, significantly impairing quality of life. Until recently, treatment was largely nonspecific and, in severe disease, sometimes ineffective and/or fraught with many side effects. Now, multiple agents targeting specific disease pathways are available or in development. Two new therapies, crisaborole and dupilumab, have become available since 2016, and dupilumab has dramatically improved outcomes for adults with severe AD. This article provides an overview of AD, including strategies for differential diagnosis and assessment of disease severity to guide treatment selection. Key clinical trials for crisaborole and dupilumab are reviewed, and other targeted treatments now in development are summarized. Two cases, representing childhood-onset and adult-onset AD, are discussed to provide clinical context for diagnosis, severity assessment, and treatment selection and outcomes.

Keywords: Adult onset; Atopic dermatitis; Crisaborole; Differential diagnosis; Dupilumab; Eczema; Infant onset; Severity assessment.

FIGURE 1.

The atopic march. The incidence of atopic dermatitis (AD) peaks early in infancy, preceding development of the atopic march. Evidence supports a causal link between AD and subsequent onset of other atopic diseases. Adapted from Czarnowicki et al. Copyright (2017), The American Academy of Allergy, Asthma and Immunology.

FIGURE 2.

Step-care management of atopic dermatitis (AD). Acute and maintenance treatments for atopic dermatitis across the spectrum of disease severity. FDA, Food and Drug Administration; TCI, topical calcineurin inhibitor; TCS, topical steroid. ^aNot an indicated dosage. ^bFor patients aged ≥2 years with mild-to-moderate AD. ^cFor adults (aged ≥18 years) or adolescents (aged 12-17 years) with moderate-to-severe AD not adequately controlled with topical prescription therapies or when those therapies are not advisable. ^dNot FDA-approved for AD. _eNot recommended for long-term maintenance. (Adapted from Boguniewicz et al with permission from Elsevier.)

FIGURE 3.

Patients achieving success in ISGA with crisaborole in AD-301 and AD-302. Kaplan-Meier analysis shows that patients treated with crisaborole achieved the studies’ primary endpoint (of clear [0] or almost clear [1] and a ≥2-grade improvement from baseline on the ISGA) sooner than did those treated with vehicle ointment (P <.001). AD, Atopic dermatitis; ISGA, Investigator’s Static Global Assessment. (Reprinted from Paller et al with permission from Elsevier.)

FIGURE 4.

AD-1526: dupilumab in adolescents with moderate-to-severe AD in AD-1526. Dupilumab was significantly more effective than control for both primary endpoints (percentage achieving an IGA score of 0 or 1 and percentage achieving EASI-75). AD, Atopic dermatitis; EASI, Eczema Area and Severity Index; IGA, Investigator Global Assessment.

FIGURE 5.

Case 1: “Eddie F.” Appearance of the pruritic rash affecting Eddie’s hands, feet, and knees. His face is also affected. Photo courtesy of Peck Y. Ong.

FIGURE 6.

Patient-Oriented Eczema Measure (POEM) Score for Eddie. The POEM for children, as completed by Eddie’s mother. Reprinted with permission from The University of Nottingham (nottingham.ac.uk/go/poem).

FIGURE 7.

Case 2: “Diana K.” Appearance of possible atopic dermatitis at presentation. A, Flexural erythema and lichenification affecting the antecubital fossa. B, Erythema and rash affecting the neck. (Reprinted from Silverberg with permission from The American Academy of Allergy, Asthma and Immunology.)