What is atopic dermatitis in adults?

A look at atopic eczema in grownups

Adult-onset atopic dermatitis(AD) is still an under-recognized medical condition as there are only a few studies regarding this disease. Compared to childhood-onset AD, distinct clinical features of adult-onset atopic dermatitis are still not categorized. It can present for the first time in adulthood with atypical morphology or may progress on from childhood. Adult-onset AD is a vital subgroup of AD with a wide range of onset ranging from 18 to 71 years. Its distinction from other eczematous disorders is essential.

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What is atopic dermatitis?

A look at atopic dermatitis in adults

Atopic dermatitis, AD (eczema) is a chronic inflammatory skin disease more commonly in children than adults. The term “Atopic” means that there is a genetic predisposition toward allergic disease. Atopic dermatitis begins in the first few years of life and is often the first indication that a child may later get asthma and/or allergic rhinitis (hay fever). In newborns, eczema appears typically as tiny bumps on the cheeks. Older children and adults often get rashes on the knees or elbows (usually in the folds of the joints), on the backs of the hands or the scalp. Symptoms of atopic dermatitis (eczema) include:

  • red or brownish patches of skin
  • Itchy skin, especially at night
  • Dry cracked or scaly skin

What was known about adult-onset atopic dermatitis?

The term adult-onset AD was created by Bannister and Freeman in 2000 when they observed that about 10% of the AD patients seen in a hospital setting were adults. After the initial information, few reports and series have been published from other parts of the world. It is probably because of the lack of the notion of adult-onset AD. It is also because the clinical idea of AD presenting in adulthood is not classical in the understanding that only the flexures are affected. Different patterns of engagement and atypical morphologies like nummular (discoid), prurigo-like, follicular, and seborrheic dermatitis may be present. Erythroderma is commonly seen, and flexural lichenification(hardening of the skin) is uncommon.With the rise in the prevalence of AD over the past few decades, adult-onset AD prevalence has also gone up, and its occurrence ranged from 1% to 3% in differing populations. Studies on AD from Singapore, Australia, and Nigeria reported that 13.6%, 9%, and 24.5%, respectively, of their Atopic Dermatitis patients, had an onset of the condition after 18 years of age.

How do you diagnose AD in adults

The diagnosis of AD is generally clinical, but diagnosis is not always easy with adults, particularly when the extension of lesions is limited, when the lesions’ distribution is atypical, when the minor cutaneous atopy signs are not present, and when atopic mucous manifestations are not associated. In many cases, the most commonly employed diagnostic criteria cannot be satisfactory, especially when AD starts when the patient is more than 18 years of age.AD is typically a childhood disease. Many adults who suffer from chronic eczema have had it nearly all their life. However, a small percentage of adults (estimated at 3% to 5%) may manifest atopic dermatitis for the first time after 18 years. Additionally, a notable number of “burned out” atopic children will manifest in adulthood with work-related hand eczema, predominantly on the grounds of a decreased threshold for irritation. This is especially true among people with an atopic diathesis who join “wet work” professions or other trades involving significant exposure to cutaneous irritants.Even though there are plenty of reports on adult-onset AD, dermatologists are more confident making a diagnosis of allergic contact eczema or airborne contact dermatitis (ABCD) rather than adult-onset AD in an adult exhibiting this cutaneous, eczematous condition. It is necessary to remember that the diagnostic criteria of Hanifin and Rajka are the gold standard and should be utilized to diagnose AD in adults.

Atopic dermatitis and allergies

ABCD or parthenium dermatitis is often indiscernible from adult-onset AD as it also affects the face, neck, and flexures. In such a case, patch testing helps eliminate ABCD. It should, however, be remembered that AD is a risk factor for allergic contact sensitivity, and contact allergy rises with age in atopic dermatitis. Extrinsic AD is more prevalent in adults than children, and both immediate and delayed allergic hypersensitivity, playing a role in parthenium-associated AD. In some of the cases of patients with positive parthenium contact sensitivity, the disease persisted despite the elimination of the allergen, and it can also be hypothesized that these may be instances of atopic dermatitis where inhalation of aeroallergens has exacerbated eczema, or it may be an apparent superimposed instance of contact dermatitis.

Smoking and Adult-onset Eczema

It is possible that smoking is a vital factor to be considered in adult-onset AD. It has been suggested that childhood exposure to passive smoking or environmental tobacco smoke raises the risk factor for AD in adulthood by almost three times, and the association is cumulative. They noted that patients with AD were significantly more likely to be current or have ever smoked than individuals without AD at 53 percent versus 18 percent.Eczema has linked with higher rates of cigarette smoking, as well as higher rates of taking alcohol, heavier alcohol consumption, and less regular vigorous activity. Eczema was also linked to higher incidences of obesity, high blood pressure, prediabetes and diabetes, and high cholesterol levels. Rates of these disorders are even higher in adults with eczema and sleep disturbance than those with eczema alone.Adult AD tends to endure, but its severity declines over the years. Head and neck eczema, high levels of serum IgE, and a long span of eczema are poor prognostic factors predicting eczema persisting for a longer period. The increased prevalence of AD in kids and the observation that it is in most adults lasts for many years imply that it is very likely that we will be seeing many older patients with AD in the future.

Treatment of Atopic Dermatitis

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The treatment of adult-onset atopic dermatitis is essentially the same as childhood atopic eczema. AD can be persistent, and you may need to try various treatments over time to control it. And even if therapy is successful, signs and symptoms may recur (flare-ups). It’s critical to recognize this condition early so that you can begin treatment. Regular moisturizing and other self-care methods may not help; your physician may suggest the following treatments:

Medications either over the counter or prescription

Creams that manage itching and repair the skin

Your doctor may order a corticosteroid cream or ointment. Use it as directed, after moisturizing. Overuse of these drugs may have side effects, including thinning skin. Other creams including drugs called calcineurin inhibitors like tacrolimus (Protopic) and pimecrolimus (Elidel) affect your immune system. They are utilized by people older than two years to help manage this skin reaction. Use it as directed, after moisturizing. Avoid staying in the sun when using these products. These medicines have a warning about the potential risk of cancer.

Drugs to fight infection

Your physician can prescribe an antibiotic cream if you get skin has a bacterial infection, an open sore or cracks. He or she may advice taking oral antibiotics for a while to treat an infection.

Oral drugs that manage inflammation

Systemic immunosuppressive agents are commonly prescribed for adults with severe and extensive eczema. Systemic corticosteroids are the most commonly prescribed medications. However, their side effects should be monitored as some of the older patients with AD may be hypertensive or diabetic. Most severely affected patients respond to cyclosporine, azathioprine, mycophenolate mofetil, or methotrexate. Recently, low-dose methotrexate is effective on adult-onset atopic dermatitis.

Newer treatment options for severe eczema cases

The Food and Drug Administration (FDA) has lately approved a new, injectable biologic (monoclonal antibody) called dupilumab (Dupixent). It is employed to treat people with severe manifestations of the disease who do not respond well to other therapy options. This is still a new remedy, so it doesn’t have a long or well-documented record in terms of how well it treats people. Studies have indicated it to be safe if used as instructed; however, it is very costly.

Alternative therapies

  • Wet dressings. An effective, intensive treatment option for severe atopic dermatitis entails wrapping the affected part with topical corticosteroids and damp bandages. Sometimes this is done at a hospital for those with widespread lesions because it’s quite labor intensive and requires some nursing expertise. Or, ask your physician about learning how to do it at home.
  • Light therapy. This treatment is used for people whose condition either doesn’t get better with the application of topical treatments or who get flare-ups rapidly again after treatment. The simplest kind of light therapy (phototherapy) involves exposing the skin to controlled amounts of natural sunlight. Other forms of light therapy use artificial ultraviolet A (UVA) and narrowband ultraviolet B (UVB) either solely or with other medications.Although it is effective, long-term light therapy has adverse effects, like premature skin aging and an increased risk of skin cancer. For these reasons, phototherapy is less likely to be used on young children and not administered to infants. Consult your healthcare provider on the pros and cons of light therapy.
  • Counseling. Speaking with a therapist or other a counselor can help those who are embarrassed or frustrated by their skin condition.Relaxation, behavior modification and biofeedback. These methods can help individuals who scratch their lesions habitually.

In summary, eczema is manageable, regardless of your age. There are many treatments options currently available, and future therapies are being discovered. With careful diagnosis and follow up with your doctor, allergist/immunologist, you can have a better quality of life.

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