What is it?
Atopic dermatitis (AD) is a chronic, relapsing, inflammatory, and intensely itchy skin disease. It is the most common skin condition in children (5-25%), but its incidence is also increasing in adults.
What Causes It?
It is a complex genetic disease, as it has been found that the interaction of genes with each other, as well as the interaction of genetic factors with environmental factors, determine the clinical manifestations of AD and their severity. More than 80 genes are linked to AD. Genetic factors cause disorders of the skin barrier and of innate and acquired immunity, which is why the effect of external factors, irritants, and allergens can trigger flare-ups of the disease.
What Are the Clinical Manifestations?
There are two clinical subtypes:
- Exogenous or allergic (affecting 85-95% of adults and 20-44% of children) with IgE sensitization to inhaled and food allergens.
- Endogenous, with normal IgE levels and no allergic reactions.
We also distinguish between three clinical types:
- Infantile type (2 months – 2 years), with a typical localization on the face (perioral, cheeks), scalp, and shins.
- Childhood type (2-12 years), where in addition to the face, the lesions appear on the flexural surfaces of the upper and lower limbs.
- Adolescent-Adult type, with manifestations also on the extensor surfaces of the limbs and a more frequent occurrence on the hands due to household and occupational activities.
How is it Diagnosed?
In addition to the diagnostic criteria that exist and are modified over the years to include clinical and immunological criteria, it is important to assess the disease severity (SCORAD), perform a differential diagnosis from other skin diseases (such as allergic or irritant contact dermatitis, nummular eczema, etc.), and conduct skin tests to check for allergens (atopy patch tests, patch tests, skin prick tests).
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How is it Treated?
The main pillars of treatment are:
- Hydration and Hygiene
Moisturizers are the basic treatment for mild forms and an accompanying therapy for chronic conditions. They aim to improve the skin barrier and relieve itching, while their systematic use reduces the need for medicated creams.
Cleansers with a pH of 5.0-5.5 do not contain allergens and are not antiseptic. They should not be used with sponges or by scrubbing. Bathing should be done in water at a temperature of 27-30°C and be followed by patting the skin dry and applying an emollient cream.
- Avoidance of Irritants and Allergens
Due to their decreased resistance to irritants, atopic skin types are more likely to develop irritant or allergic dermatitis, which is why they must be avoided. Irritants that have been implicated include soaps, detergents, antiseptics, perfumes, water, wool or synthetic clothing, cigarette smoke, atmospheric pollutants, and heat due to the irritating sweating it causes, as well as high humidity for the same reason.
- Therapeutic Education
There is a wealth of practical advice for the daily care of people with atopic skin. Indicative examples include:
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- Room temperature of 19°C.
- Regular airing of the house and shaking out bedding.
- Avoidance of wool bedding and down pillows.
- Avoidance of carpeting and rugs.
- Use of an electric vacuum cleaner instead of a simple broom.
- Wearing loose-fitting cotton clothes.
- Avoiding stress, which is an aggravating factor.
- Avoiding scratching and injuring the skin.
- Medical Treatment
Medical treatment is recommended by the treating dermatologist and can be topical and/or systemic.
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- Topical preparations include topical corticosteroids that have an anti-inflammatory effect to treat flare-ups, and topical calcineurin inhibitors (pimecrolimus, tacrolimus) that do not cause skin atrophy and are given for treatment and for a longer period of time than corticosteroids.
- Systemic therapy mainly includes antihistamines for itch control and systemic corticosteroids for a very short period in the acute phase, while other preparations, such as cyclosporine, are used to treat primarily chronic, persistent eczema.
- New targeted therapies of recent years.
The management of atopic dermatitis has changed radically in recent years, mainly thanks to the development of new, targeted therapies. In contrast to older treatments that mainly managed symptoms, these new treatments act in a targeted way on the underlying mechanisms of the disease, providing significant relief.
New Therapies for Atopic Dermatitis
The most important developments concern two main categories of drugs:
- Biological Agents, which are a class of drugs that target specific molecules (proteins) of the immune system that are responsible for the inflammation and itching of atopic dermatitis. The most well-known example is dupilumab, which blocks the receptors for interleukins IL-4 and IL-13, two central cytokines in atopic inflammation.
- How are they administered? By subcutaneous injections, usually every 2 or 4 weeks.
- For whom are they? They are intended for patients with moderate to severe atopic dermatitis who do not respond to topical treatments.
- JAK Inhibitors (Janus Kinase inhibitors). This is another class of targeted drugs, known as “small molecules,” that interfere with inflammation signals within the cells themselves.
- What are they? They act by inhibiting the JAK enzymes, which are critical for transmitting the signals of cytokines (such as IL-4 and IL-13) that cause inflammation.
- How are they administered? They are administered orally, in the form of a pill.
- The main JAK inhibitors that are approved for atopic dermatitis and are administered in pill form are as follows:
- Upadacitinib
- Baricitinib
- Abrocitinib
- For whom are they? Like biological agents, they are approved for the treatment of moderate to severe atopic dermatitis.
Key Benefits of New Therapies
- High Efficacy: They offer impressive results in controlling symptoms, such as severe itching and skin plaques.
- Significant Improvement in Quality of Life: By reducing itching and flare-ups, they dramatically improve patients’ sleep, mood, and social relationships.
- Targeted Action: They act selectively on the mechanisms of the disease, which makes them safer compared to older systemic treatments.
It is important to emphasize that these therapies are administered exclusively under the supervision of a dermatologist, who will evaluate the patient’s condition and determine the most appropriate treatment.
Why Should I Treat My Eczema?
The need to treat atopic eczema is necessary and urgent because it has been found that persistent atopic inflammation in the skin increases the likelihood of atopy in other organs and systems. Therefore, only the treatment of the disease on the skin can prevent this progression.
The dermatologist is the specialist doctor who can diagnose and treat atopic dermatitis at any age.