Atopic Dermatitis in Adults: A Diagnostic Challenge

Abstract

Atopic dermatitis (AD) has a prevalence of 1%-3% in adults. Adult-onset AD has only been defined recently, and lack of familiarity with this condition and confusion regarding the appropriate terminology persist. AD may first appear in childhood or de novo in adults and is characterized by pronounced clinical heterogeneity. The disease often deviates from the classic pattern of flexural dermatitis, and there are forms of presentation that are specific to adults, such as head-and-neck dermatitis, chronic eczema of the hands, multiple areas of lichenification, or prurigo lesions. Although diagnosis is clinical, adult-onset AD frequently does not fit the traditional diagnostic criteria for the disease, which were developed for children. Thus, AD is often a diagnosis of exclusion, especially in de novo cases. Additional diagnostic tests, such as the patch test, prick test, skin biopsy, or blood test, are usually necessary to rule out other diseases or other types of eczema appearing concomitantly with AD. This article presents an update of the different forms of clinical presentation for AD in adults along with a proposed diagnostic approach, as new treatments will appear in the near future and many patients will not be able to benefit from them unless they are properly diagnosed. Key words: Atopic dermatitis. Adult. Diagnosis. Patch testing. Prick testing. ResumenLa dermatitis atópica (DA) en el adulto tiene una prevalencia del 1-3%. Es una entidad de reciente acuñamiento, que no todo el mundo conoce y sobre la que existe una gran confusión terminológica. Puede iniciarse en la infancia o presentarse de "novo" en el adulto. Presenta una gran heterogeneidad clínica y con frecuencia no sigue el patrón clásico de dermatitis flexural. Además, existen formas de presentación más propias de adulto como son la dermatitis de la cabeza y el cuello, eczema crónico de manos, áreas de liquenificación múltiple o lesiones de prurigo. Aunque su diagnóstico es clínico, muchas veces la DA del adulto no cumple los criterios diagnósticos "clásicos" de DA, pues están pensados para niños. Por eso, suele ser un diagnóstico de exclusión, sobre todo los casos de "novo". Suele precisar de la realización de pruebas diagnósticas para descartar otras enfermedades distintas u otro tipo de eczema sobreañadido a la DA. Las pruebas diagnósticas que pueden resultar útiles para ello son: pruebas epicutáneas, prick test, biopsia cutánea y una analítica sanguínea. Realizamos una actualización de las distintas formas de presentación clínica de la DA del adulto y establecemos unas pautas para llegar a su diagnóstico, pues en un futuro inmediato, con la aparición de nuevos tratamientos, muchos de estos pacientes no podrán beneficiarse de los mismos por no estar adecuadamente diagnosticados. Palabras clave: Dermatitis atópica. Adulto. Diagnóstico. Pruebas epicutáneas. Prick test.

Chronic prurigo: A retrospective study of 168 cases

“…Estrogen enhances type 2 responses and promotes increased production of Th2 cytokines, including IL‐4, IL‐5 and IL‐13 . Atopic dermatitis (AD), for example, a well‐known Th2‐mediated inflammatory condition, predominantly affects women . This is, however, inconsistent with our findings of increased prevalence of PCM in men.…”

“…This is, however, inconsistent with our findings of increased prevalence of PCM in men. Notably, the sex distribution trend observed in AD is reversed in individuals over 65 years of age, with more elderly males affected than women . We therefore speculate that similar mechanisms may account for the high prevalence of PCM in males, a disease that also is common in the elderly.…”

Efficacy and safety ofPAC‐14028 cream – a novel, topical, nonsteroidal, selectiveTRPV1 antagonist in patients with mild‐to‐moderate atopic dermatitis: a phaseIIb randomized trial

“…However, the treatment effects were not statistically significant owing to the relatively small sample size and the lack of children included in the study. The typical forms of clinical presentations of AD in adults differ from those in children and generally include inflammatory eczema with a larger area of lichenification, nummular eczema, and/or prurigo and are more resistant to topical therapy . Successful treatment of AD with tacrolimus 0·03% or crisaborole was achieved in a greater proportion of patients in paediatric groups than those in adult groups …”

Fifty‐two week follow‐up safety and effectiveness results of dupilumab treatment of moderate‐to‐severe atopic dermatitis from a retrospective, multicentric series

“…Although the dysfunction of the cutaneous barrier and the immune alteration are the main disorders in these patients, the causality of this relationship is not known accurately. AD usually starts in early infancy, evolute with a recurrent course before disappearing at adolescence, although it may persevere to adulthood or present de novo during this period (Silvestre Salvador, Romero‐Pérez, & Encabo‐Durán, ).…”