Atopic dermatitis — SAQ

Stem

A 16-year-old has chronic itchy flexural eczema since infancy, worse at night, with asthma in the mother. Emollients and topical steroids have not controlled sleep or school. EASI is 18, IGA 3, BSA 12%. There is no fever and no punched-out erosions. ^[22][1]

Questions

a) Define atopic dermatitis and give the childhood and adult prevalence figures from Nutten 2015. Name the comorbidities that travel with it. (2 marks)

• Chronic inflammatory skin disease with a wide spectrum of presentations; up to 20% of children and up to 3% of adults; prevalence still increasing, especially in low-income countries.^[23]
• First manifestations usually appear early in life and often precede asthma or allergic rhinitis.^[23]
• Langan: associated with food allergy, asthma, allergic rhinitis and mental-health disorders; leading cause of the global burden from skin disease.^[1]

b) Grade this patient's severity using Leshem EASI bands and name the Measure Up / JADE MONO-1 systemic-trial entry set. (3 marks)

• Leshem 2015: 0 clear; 0.1–1.0 almost clear; 1.1–7.0 mild; 7.1–21.0 moderate; 21.1–50.0 severe; 50.1–72.0 very severe. EASI 18 is moderate.^[22]
• Trial entry (not an unsourced DLQI composite): EASI at least 16, IGA or vIGA-AD at least 3, BSA at least 10% after inadequate topical control.^[9]
• Treat-to-target in the pivotal programmes is EASI-75 or IGA 0/1 by week 16 (week 12 for JADE MONO-1).^[8]

c) Outline stepwise management and the AAD 2024 systemic recommendations that apply once topicals fail. (3 marks)

• Foundation: moisturizers (AAD 2023 strong recommendation) plus trigger avoidance.^[3]
• Topical corticosteroids matched to site; calcineurin inhibitors for face and folds.^[3]
• Phototherapy: AAD 2024 conditional recommendation if topicals fail.^[12]
• Strong recommendations: dupilumab, tralokinumab, abrocitinib, baricitinib, upadacitinib. Conditional: azathioprine, ciclosporin, methotrexate, mycophenolate. Against systemic corticosteroids.^[12]
• Dupilumab 300 mg weekly or every other week: SOLO 1 IGA 0/1 38% and 37% vs 10%; SOLO 2 36% and 36% vs 8%.^[8]

d) Which emergency rash must this family be taught to recognise, and what is the immediate action? (2 marks)

• Eczema herpeticum — widespread monomorphic punched-out erosions with fever, malaise, or cold-sore contact.
• Start systemic aciclovir promptly; consider admission if young, extensive, or systemically unwell. Do not wait for the swab in a deteriorating patient.^[1]

Marking tips

Do not award the unsourced 15–20% / 2–10% adult band, a DLQI-at-least-11 AAD gate, or “anti-IL-13 has a lower ocular signal”. SOLO percentages and Leshem bands must be exact. ^[23][22][8]

References7ShowHide

1. [3]Sidbury R, Alikhan A, Bercovitch L, et al. Guidelines of care for the management of atopic dermatitis in adults with topical therapies. J Am Acad Dermatol, 2023.PMID 36641009
2. [1]Langan SM, Irvine AD, Weidinger S. Atopic dermatitis. Lancet, 2020.PMID 32738956
3. [9]Guttman-Yassky E, Teixeira HD, Simpson EL, et al. Once-daily upadacitinib versus placebo in adolescents and adults with moderate-to-severe atopic dermatitis (Measure Up 1 and Measure Up 2). Lancet, 2021.PMID 34023008
4. [8]Simpson EL, Bieber T, Guttman-Yassky E, et al. Two Phase 3 Trials of Dupilumab versus Placebo in Atopic Dermatitis. N Engl J Med, 2016.PMID 27690741
5. [12]Davis DMR, Drucker AM, Alikhan A, et al. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol, 2024.PMID 37943240
6. [22]Leshem YA, Hajar T, Hanifin JM, Simpson EL What the Eczema Area and Severity Index score tells us about the severity of atopic dermatitis: an interpretability study. Br J Dermatol, 2015.PMID 25580670
7. [23]Nutten S Atopic dermatitis: global epidemiology and risk factors. Ann Nutr Metab, 2015.PMID 25925336