Atopic Dermatitis in Adults: Challenges and Treatment Strategies

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On day 1 of the American Academy of Dermatology Annual Meeting 2024, a session covered the differences in presentation, treatment, and care when treating patients 18 years and older who have atopic dermatitis (AD). The presentation, given by Jonathan I. Silverberg, MD, PhD, MPH, FAAD, director of clinical research at The George Washington University School of Medicine and Health Sciences, highlighted which types of AD were more commonly treated in adults and how to go about addressing their challenges.

AD Presents Differently in Different Ages

AD, according to Silverberg, can appear in all types of ways in different age groups. Infants primarily display facial and scalp dermatitis. The reason for this is unknown said Silverberg, noting, “In [AD] we have much less real insight translationally as to why the face, in particular, over other parts of the body and why some patients will progress differently in that in terms of their temporal course.”

Infant with skin irritation | Image credit: Diego - stock.adobe.com

In adult patients, however, the head and neck are common locations for patterns of AD, Silverburg added. Further, a lot of adult patients with head or neck AD had AD as children, but hadn’t experienced disease spread until adulthood. Chronic dry scaly lesions are more common in adults rather than the inflamed red areas pediatric patients typically exhibit, in all of the face, neck, and hands. This can make diagnosing AD difficult, as doctors could classify it as either AD or contact dermatitis. But, Silverberg said, this can all be an evolving pattern of that same AD, which makes it hard to make a quick diagnosis, as you want to give your patients the best treatment for them.

A previous systematic review of Silverberg's shows how AD presentation varies in children and adults. This review found that adults made up more cases of lichenification (100% vs 48%), urticaria (32% vs 20%), prurigo nodularis (18% vs 4%), and popular lichenoid lesions (46% vs 8%), among others, compared with children. Hand or foot dermatitis (44% vs 25%), knuckle dermatitis on hands (25% vs 8%), and fissured heels (12% vs 8%) were also more common in adults.

Children more often had ventral wrist dermatitis (34% vs 15%), exudative eczema (61% vs 42%), pityriasis alba (28% vs 18%), and perifollicular accentuation (37% vs 21%), among others. A study Silverberg highlighted found that a history of AD was associated with increased odds of irritant hand eczema (adjusted OR, 1.358; 95% CI, 1.275-1.447).

However, there were also similarities between the 2 groups. Extensor involvement is 25% in children and 24% in adults and facial dermatitis was 39% in children and 38% for adults.

“We were often taught over decades that extensor involvement is only a thing relevant in toddlers. And often we thought it was because they were crawling and they were on carpeting and there was friction… That appears to be nonsense. So I will scrap that from your vernacular,” said Silverberg.

Chronic rubbing can also worsen these conditions, as patients can lose hair in their eyebrows, and chronic picking can worsen the rash itself. Both of these are more common in adults. This chronic scratching, rubbing, and picking that presents in adults can be an obstacle to figuring out the correct diagnosis and treatment.

Silverberg suggested that patch testing should be done when adolescent- or adult-onset AD must be differentiated, when lesion distribution is atypical or suggestive of contact dermatitis, if a patient is starting a systemic therapy for AD, if the AD gets worse with therapy, or if the dermatitis is recalcitrant to topical therapy. However, he acknowledged that many people in the United States will not ever get a patch test due to the availability.

“So 90% or 95% of the US population will never get a patch test, even if they need it,” he said. “But if they live in rural America…they’re not getting access to patch testing. It’s just an issue… The reality is, in those adult-onset cases, we’re probably nationwide and globally missing a whole lot of contact dermatitis.”

Older adults also have their own presentation of AD, according to Silverberg. Targeted therapies can be good in this population but their other skin diseases could end up worsening if you use the wrong targeted therapy. Going more broad is also possible, but topical steroids in the older adult population could be a challenge due to their fragility. So caution is advised.

Treatment of AD in All Populations

The basic treatments for AD can be separated into 3 main categories: basic management, prescription topical therapy, and systemic or phototherapy. The first 2 are used for all types of AD severity whereas systemic or phototherapy is more often used in moderate to severe AD.

Basic management, said Silverberg, can be simple things like general skincare, bathing recommendations, and trigger avoidance. However, doctors often skip over this in favor of going right to medications that can be given, which can be a cause for concern in patients. As far as starting those medications, shared decision-making is paramount in deciding how to approach these different therapies.

Topical treatment, such as steroids, are still a mainstay in AD because of the comfort level from most doctors. The right guidance should be given to explain to patients the safety of the medicine on their skin and the potential adverse effects, and to find a regimen that is feasible for the patient, as some patients may not be able to apply lotions or creams twice a day, which some topical treatments require. Setting a realistic timeframe and telling them how long the treatment will be needed is also a requirement.

Phototherapy is also a possibility, but is inaccessible to a lot of patients due to having to be treated 2 to 3 times a week. For moderate to severe AD, biologics like dupilumab and tralokinumab and oral systemic immunomodulators such as abrocitinib, baricitinib, and upadacitinib are options but are often prescribed off label. Silverberg presented the results of several studies showing the efficacy of these off-label drugs, with upadacitinib in a 30-mg dose outperforming abrocitinib and dupilumab after 12 weeks.

"Combination therapy should also be considered," he said. Combining dupilumab 300 mg with upadactinib 30 mg after 24 weeks on dupilumab alone was able to outperform upadactinib alone through 40 weeks in patients with moderate to severe AD. Forty-two percent of patients on the combination therapy achieved Eczema Area and Severity Index (EASI) 100 after 40 weeks compared with 34% on upadatinib alone. Additionally, 97% of patients on combination therapy achieved EASI 75 compared with 92% on upadactinib alone, according to the results of a previous study.

Silverberg acknowledge that all doctors should be careful about interpreting these data. “One of the reasons why you need to be careful in how you interpret these data is because the kinetic profiles of these drugs are very different… We have to understand that it’s not like this disease is a 16-week long disease, and for many patients, they will get far more benefit beyond week 16 or what you see at week 16,” he said.

Communication Is Most Important When Treating AD

Silverberg concluded the session by emphasizing that communicating with patients about what their goals are and what they expect out of treatment is crucial to treating AD. Having a team meeting with the patient to gather what type of medication they will or will not take is important in making sure your time isn’t wasted trying to push a treatment the patient does not want. It can also help to establish if the patient is more willing to try an experimental therapy.

“If you really do this, you can really then match up the right drug for the right patient,” said Silverberg. “If you have that shared decision and you are honoring and respecting the patient’s preferences and this is what they want, then you’re not going to have these issues.”

Treating AD in patients of all ages can be difficult but being able to establish what it is that the doctor is treating and pinpointing which treatment works best and is something the patient is ok with using can make the process easier for both doctor and patient, he underscored.