Learn more about the atypical presentations of atopic dermatitis (AD) and review methods to help enhance AD patients' understanding of the condition. 

Transcript: 

Hi, thanks for joining today. My name is George Han. I'm an associate professor of dermatology at the Icahn School of Medicine at Mount Sinai, as well as the Zucker School of Medicine at Hofstra Northwell. 

Today, we'll be talking about atypical presentations of atopic dermatitis, and this is a topic that's near and dear to my heart because I actually have an atypical form of atopic dermatitis. This leads to our first topic, which is actually atypical presentations in Asian patients, and it's interesting because there's a lot of work that's been done here. 

You might know the pathophysiologic work that's been done showing that there's actually TH17 inflammation, which we usually connect to psoriasis, but that's elevated in Asian patients with atopic dermatitis as opposed to Caucasians. This work comes out of Emma Guttman's lab at Mount Sinai and a lot of really interest there. But when we see how it plays out in clinical practice, we have patients such as one here that you can see that has pretty classic lesions, I would say, on the neck. 

But once you go and take a look at her back, you have this really strikingly well demarcated, very erythematous lesion here that frankly was quite confusing. So, we actually biopsied this and it came back consistent with eczema spongiotic dermatitis.  

We got the patient on appropriate treatment. Turns out she actually later ended up developing psoriasis as well. So again, talking about that kind of a little more, less clarity between these 2 conditions. I think you can definitely see that. Or my own case, which is that when I go out into the sun after my skin's been covered up for the winter, my eczema flares up. It's interesting because it behaves a little bit like the spring eruptions that we see, maybe the solar-induced forms of lymphocytic dermatoses. But again, it's classic eczema. We actually see this more with Asian patients, and you'll see some elements of hardening as well.  

So, it's important to keep in mind that everybody's triggers can be really different, and even though the textbooks say that the sun is supposed to make eczema better because, in essence, it's a form of phototherapy, not everybody reacts the same way.  

The second topic we'll talk about is again an atypical form of eczema that's more confusing in its diagnosis than anything else. The patient that you see here has follicular eczema, and this was confusing enough because it was so well demarcated as well in specific areas the body that we actually biopsied and were concerned about a true folliculitis being the primary cause.  

But again, no infection here, just bad follicular eczema. You'll see a lot of these patients coming in where they have eczema, maybe they'll have keratosis pilaris, and it's hard to know where one starts and one ends. But again, just, you know, keep in mind the symptoms help you, the onset development, the history all help to get to a diagnosis. This patient thankfully responded to topical steroids, but you'll see that really follicular prominence and predominance in some of our patients along with predominant lichenification as well. 

These are cases we don't want to underestimate the severity [of] because there may be a lot of erythema hiding there under the hyperpigmentation that we're not fully appreciating as we would if it was a lighter skin type.  

The last thing we'll mention here is a form of eczema that actually we need to take very seriously and urgently. This patient actually came in. The mother said that they've been scratching, they've been having a typical eczema flare, but this area around the knee just started kind of rapidly expanding. 

When we look carefully, you see those scalloped borders. You see those punched-out erosions. This is eczema herpeticum, and it's something we need to take very seriously. We need to get this patient on antivirals right away and make sure we also get their eczema flair under control at the same time. 

So, how do we do that, and how do we reconcile getting them on antivirals but also putting on a topical steroid that may suppress their cutaneous immune system? So, usually what I do for these patients is for the area that's involved with the eczema herpeticum specifically, we actually would just put something like mupirocin so we prevent impetiginization, but also, we're not giving a topical steroid yet. Once everything starts to crust over, then if it's still itchy, you can shift over to the topical steroid, but during the time when it's still very active, you know, it's all hands on deck to get rid of the infection first. So, hopefully that's given you some tips and hints about these atypical presentations of atopic dermatitis. 

Thank you for your time.