Q&A: Eczema Awareness Month highlights atopic dermatitis heterogeneity

The National Eczema Association has dedicated October to raising eczema awareness, with 2021 focused on the varied disease experiences among those living with and caring for this condition.

Eczema is a chronic, non-contagious skin disease affecting 31.6 million adults and children in the U.S., but each person experiences its daily obstacles and long-lasting burden differently. The disease is often debilitating, with 40% of people turning down employment or educational opportunities and 5.9 million workdays lost every year because of it, according to the National Eczema Association (NEA).

Vivian Shi, MD, FAAD, associate professor of dermatology at University of Arkansas for Medical Sciences, has the unique perspective of both studying eczema through research and clinical experiences, as well as personally being diagnosed with the disease.

In light of Eczema Awareness Month, Shi discussed what the diversity of eczema means for patients, caregivers and clinicians.

Healio: What types of eczema are there?

Shi: Eczema is a general term. It refers to dermatitis and could be any condition that is related to inflammation of the skin. The classic “eczema” is called atopic dermatitis, which has a number of features on the skin and several comorbidities that are related to allergies such as allergic rhinitis, asthma and food allergies. Here we focus our discussion on atopic dermatitis. Traditionally, we used the classic Hanifin and Rajka criteria to diagnose atopic dermatitis, but if you look at these criteria, it will have many checkmarks that one has to meet. Many people who have atopic dermatitis may not fulfill all the criteria needed for its diagnosis. The newer line of thinking suggests that although everyone may not strictly meet those criteria, they can still have atopic dermatitis or eczema. It is very heterogeneous. The world of eczema is moving away from the black-and-white type of guidelines to more fluid criteria.

Healio: What should clinicians look for most in patients with eczema?

Shi: All dermatologists can start with an objective assessment of the skin — looking at the individual lesion morphology and severity, followed by body surface area involvement and evaluating how the lesions change with time. What is also very important is asking about patient-reported symptoms such as itch, skin pain, difficulty sleeping and interference of activities of daily life. These subjective measures can have a significant impact on a patient’s quality of life. Therefore, clinicians should consider both objective and subjective evaluations to develop a more comprehensive picture for each patient.

Healio: What can trigger disease flare-ups?

Shi: That is the billion-dollar question. Every patient may have different triggers, and we have not identified the root cause for atopic dermatitis yet. It would be awesome if I could say, “it’s definitely watermelon you ate 2 weeks ago triggered your eczema flare.” But unfortunately, it is not that simple. Most likely, it is multifactorial. Environmental, genetic, skin barrier and lifestyle causes can all have an impact. But more commonly, there are specific triggers, such as change in weather, pollen, travel or increase in stress. The frequent use of hand sanitizers these days is a very common trigger because they are alcohol-based products that can lead to skin dryness by drawing water out of the skin, and eczema patients are already prone to dry skin. Once again, triggers can be unique to each eczema patient and clinicians can try to work with patients and their caregivers to keep a trigger diary.

Healio: How does this disease burden patients?

Shi: Overall, it is the quality of life that we evaluate, and it is defined differently with every patient. It could be the ability to work and make a living, sleep or relationships. That is why it is important for clinicians to work with patients to define priorities as well as short-term and long-term goals. For example, a patient had told me, “I just want my back to get clear so I can go to my homecoming dance with a backless dress.” If that is a concrete short-term goal, we can work toward that. Some patients may be less concerned about the appearance of their skin, and rather tell me “I want the itch to be better, I want to sleep 6 hours straight at night without waking up to scratch.” In that case, we may tailor the treatment differently, because that is the patient’s immediate priority.

Healio: What treatment and management options are there for the disease?

Shi: Various expert groups have published treatment guidelines, but it is commonly a therapeutic ladder according to disease severity. Oftentimes monotherapy, which is a single therapy, is not sufficient enough to get us to the finish line. We typically like to design a toolbox — or multimodal therapy — where each component targets a potential trigger for eczema or an eczema flare. Most of the time, every patient should practice gentle skincare and skin barrier repair with liberal moisturizer use and strategic bathing regimens. Additionally, there will be topical prescription medications including topical corticosteroids, topical calcineurin inhibitors (tacrolimus, pimecrolimus) and topical phosphodiesterase inhibitor (crisaborole). Most recently, a topical Janus kinase (JAK) inhibitor, ruxolitinib, was approved. As the disease severity progresses, such as in moderate to severe individuals or individuals without adequate control with topical treatments, we consider systemic therapy. Systemic therapies can include traditional immunosuppressants or newer immunomodulators such as a biologic. The only biologic that is approved for moderate to severe eczema is Dupixent (dupilumab, Regeneron/Sanofi) which has been a game changer for eczema treatment to achieve rapid and efficacious results. Currently, it is approved in adults and children aged 6 years and older. Hopefully, Dupixent will be approved for even younger children very soon.

Healio: What is the best way to support someone who has eczema?

Shi: There may be barriers for patients in different stages of care. Getting to the doctor is a barrier, so we need to educate the patient community to seek care earlier. The next step is finding the right provider for their eczema. Going to a dermatologist, preferably someone who specializes in eczema, will be very beneficial. They may have more experience and comfort in prescribing eczema-specific treatments and designing a comprehensive toolbox. Another consideration is, as clinicians and clinician educators, we need to educate our peers who are prescribers on the complexity of eczema, the available treatments, and the dynamic disease states — times of remission and flare. The treatment toolbox should be adjusted according to the disease severity and the needs of the patient. And last but not least, I'm always up for more research, which leads to better understanding and ultimately development of newer, better and safer medications.

Healio: Is there anything else you would like to add?

Shi: The NEA is the biggest and reliable advocacy group in the U.S., so I recommend that my peers refer patients to the NEA website for up-to-date information. The NEA has a seal of approval product program — if someone is looking for more eczema-appropriate products, from clothing to moisturizers to makeup, they have comprehensive recommendations. Their recommendations tend to be safer and more tolerable on eczema skin. Another great tool is EczemaWise, the NEA eczema tracker app. It allows patients to track their symptoms, flares, triggers and medication adherence in a one-stop-shop app. It is a great tool for patients to track their own disease, but also as a summary tool to communicate with their doctors about symptoms and triggers they are experiencing in between visits. This can help facilitate communication to develop a shared decision-making strategy for their eczema.

Reference:

NEA's Eczema Awareness Month 2021 Explores The Heterogeneity Of This Life-altering Skin Disease That Burdens 1 In 10 Adults And Children In The USA. https://www.prnewswire.com/news-releases/neas-eczema-awareness-month-2021-explores-the-heterogeneity-of-this-life-altering-skin-disease-that-burdens-1-in-10-adults-and-children-in-the-usa-301389575.html. Published Oct. 1, 2021. Accessed Oct. 11, 2021.