Myth: Atopic Dermatitis Does Not Start in Adulthood
Atopic dermatitis (AD) typically first appears in childhood and tends to disappear before puberty begins; however, some patients experience AD that persists into adulthood or occurs de novo. Bannister and Freeman coined the term adult-onset atopic dermatitis after reviewing 2604 cases of AD and noting that 243 patients (9%) were first diagnosed with AD at 20 years of age or older. Adult-onset AD may be its own subset of AD or childhood AD that was simply not diagnosed until adulthood or was forgotten by the patient.
Characteristically, AD presents in adults as inflammatory eczema with areas of lichenification. It could occur after a change in residence to a cold dry climate or exposure to central heating, as patients who grew up in warm, sunny, humid climates might not have had diagnosable AD in childhood or adolescence. The more common forms of adult-onset AD are hand and neck dermatitis, hand eczema, nummular eczema, or prurigo, while childhood AD often manifests in a flexural distribution. Because it is difficult to detect, adult-onset AD is diagnosed after ruling out other diseases. Diagnostic procedures, such as patch tests, skin prick tests, biopsies, or blood screenings, usually are necessary to rule out other diseases or types of eczema. Contact eczema is the first diagnostic sign of AD in adults.
Maintaining AD in the differential diagnosis for patients with clinical symptoms of pruritus and eczema is essential due to the quality of life impact of the condition. Sleep disturbance is common in adults with severe AD and treatment may help to improve sleep quality.
Hanifin suggested the following when assessing adults for AD:
- Verify diagnosis (not allergic contact dermatitis or psoriasis)
- Determine patient's history of allergies (eg, food allergy) or childhood eczema
- Obtain family history of eczema/allergies
- Evaluate if patient's occupation may impact condition (eg, contact with irritants or known contact allergens)
- Inquire about patient's childhood residence (eg, tropical climate)
Adult-onset AD is a recalcitrant condition that can be difficult to treat, and appropriately labeling/diagnosing the condition will lead to better management.
Expert Commentary
Whereas once it was the rite of the pediatric AD patient to outgrow disease, it has now become clear that resolution is not as hard a stop in atopic disease as expected. Adult-onset and persistent disease in AD is clearly a significant problem, especially in developed nations and carries a host of comorbidites. Time and enhanced research will hopefully identify interventions to reverse the trend towards persistence into adulthood.
—Nanette B. Silverberg, MD (New York, New York)