Raj Chovatiya, MD, PhD, is Assistant Professor of Dermatology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. Dr Chovatiya also directs the Eczema and Itch Clinic where he focuses on chronic inflammatory skin disease, particularly atopic dermatitis and eczema, but also other chronic inflammatory conditions like psoriasis and hidradenitis. He met with The Dermatologist to discuss one of his recent studies with us, titled, “Clinical phenotyping of atopic dermatitis using combined itch and lesional severity”.1
Transcript
Dr Chovatiya: There is a couple of things that we need to follow up on with this study. One, this was a single centered study at one large academic center in the Midwest, and to get the richest data, this type of analysis should be carried out in perspective in large scaled multicentered way.
We're starting to do this in atopic dermatitis, but we definitely have a long way to go to build up the largest data that we can. One interesting finding that occurred in our study with patients that had severe itch and severe lesions were more likely to be older and identified as male and Black, whereas patients with severe itch and milder lesions were more likely to identify as female and Black.
Previous studies have shown that female sex is associated with increased prevalence, but not specifically itch severity. Additionally, Black race itself has been shown to be associated with increased atopic dermatitis severity, likely from a combination of both intrinsic and extrinsic factors.
However, in our study, the increased proportion of people with severe itch and severe lesions, or severe itch and milder lesions among Black patients suggests some unique risk factors and greater need for antibiotic therapy in its population. Those are things that we think that in general, we need to follow up on.
Last, our results show that patients with atopic dermatitis that have severe itch have a less stable force and worse prognosis over time than those with milder itch, similar to those with severe lesions.
What does this mean for treatment? Currently, our guidelines recommend the use of proactive treatment with topical anti inflammatory therapies to sites that are prone to eczema flare on the skin.
What does it mean for people that have severe itch, let's say, but not necessarily really severe lesions? We need to better understand the optimal prevention approaches for severe itch, with or without severe lesions.
Our findings showed that its severity and impact among atopic dermatitis patients with milder lesions is probably underappreciated. We need to maybe reconsider how we think about atopic dermatitis severity when evaluating your standard patient in clinic.
If we were to focus on the physical exam findings, we might be biasing our assessment of severity and missing a large group of people that have milder lesions, but more severe itch. Clinician should assess itch severity in all patients with atopic dermatitis.
One solution is to be routine use of a single item numerical verbal rating scale for itch. These have been shown to be valid, reliable, feasible, easy to use in clinical practice, and take no time at all.
This is a work in progress right now, but there are exciting studies coming out every day. We're beginning to understand that even beyond clinical signs and a symptom like itch, the burden of other symptoms like pain or disturbances in sleep and mental health, or even both atopic and non atopic comorbidities is real, and their spectrum of quality life is different for every patient.
The next frontier of atopic dermatitis research is going to be figuring out how to select optimal treatment and to predict a disease course and overall outcome. For now, simply listening to your atopic dermatitis patients reveals quite a bit about their disease.
Simply put, atopic dermatitis is not a one size fits all disease. The heterogeneity exists well beyond standard disease classifications that we think about, mild, moderate, and severe.
Instead of relying on anyone specific measure of severity, let's say, the physical exam, you should take the time with our patients to understand the full burden of atopic dermatitis, like its severity or other factors, and let that guide the treatment plan.
Reference
1. Chovatiya R, Lei D, Ahmed A, Chavda R, Gabriel S, Silverberg JI. Clinical phenotyping of atopic dermatitis using combined itch and lesional severity: A prospective observational study. Ann Allergy Asthma Immunol. Published online April 2, 2021; S1081-1206(21)00220-9. doi:10.1016/j.anai.2021.03.019
