In this episode of Topical Conversations, Drs. James Q. Del Rosso and Lisa Swanson explore the concept of the atopic march and the critical importance of early intervention in atopic dermatitis (AD). They discuss strategies for addressing AD in young patients, the potential to prevent progression to other atopic comorbidities, and how to navigate conversations with parents about treatment options. 

Understanding the atopic march 

Dr Swanson highlights that atopic dermatitis often marks the starting point of the atopic march, a progression that can lead to other atopic conditions such as food allergies, asthma, and allergic rhinitis. While genetics lay the foundation, environmental factors, the skin and gut microbiomes, and skin barrier dysfunction can trigger the cascade of events that lead to AD and other atopic diseases. 

Recent studies suggest a connection between AD and food allergies, pointing to how a compromised skin barrier allows aerosolized food particles to interact with the immune system abnormally. 

The role of skin care in mitigating the atopic march 

Dr Del Rosso acknowledges that evidence is limited regarding whether early skin care can prevent the atopic march, but he strongly advocates for measures that protect and restore the skin barrier. He emphasizes controlling environmental exposures, reducing the use of fragranced products, and promoting the use of sensitive skin care products. 

Dr Swanson reinforces the importance of explaining the dual nature of AD to parents: 

1. Skin barrier dysfunction: The barrier is compromised, allowing irritants and allergens to penetrate 
2. Overactive immune response: The immune system overreacts to normal stimuli, driving inflammation 

By framing treatment as a 2-pronged approach—nurturing the skin barrier with appropriate products and calming inflammation with medications—Dr Swanson finds parents better understand the importance of adherence to the treatment plan. 

The potential of systemic therapies to alter the atopic march 

Both Dr Swanson and Dr Del Rosso discuss the emerging evidence supporting the use of systemic therapies, particularly dupilumab, in young patients with AD. Dupilumab, which targets type 2 inflammation, has demonstrated effectiveness in not only treating AD but potentially reducing the risk of other atopic conditions, including asthma and food allergies. 

Dr Swanson shares a case of a 6-month-old with moderate AD. After initially treating with topicals, she introduced the idea of dupilumab to the family, citing data suggesting its ability to reduce the impact of atopic comorbidities. While the initial treatment improved symptoms slightly, the family ultimately decided to proceed with dupilumab, with Dr Swanson emphasizing its potential long-term benefits. 

Dr Del Rosso agrees, referencing data that suggests dupilumab may lessen the severity of asthma or allergic sinusitis if used early. However, he notes the need for more robust long-term studies to confirm these findings. 

Navigating conversations with parents 

Introducing systemic treatments such as dupilumab to families can be challenging, particularly when injectables are perceived as more “severe” than topical or oral treatments. Dr Swanson advises a gradual approach: 

• Plant the seed early: Introduce the concept of systemic treatment as a possibility, allowing families time to consider the option 
• Address misconceptions: Explain the significance of treating AD thoroughly and the potential ramifications of delaying care 
• Build trust: Begin with topical treatments where appropriate to establish a connection with the family, then revisit systemic options if necessary 

Dr Swanson notes her frustration with the minimization of AD’s impact, particularly by primary care providers who may suggest children will "outgrow" the condition. While this may be true in some cases, she emphasizes that appropriate management is critical to improving their quality of life and mitigating future risks. 

The unanswered question: how early should we intervene? 

One outstanding question is how early intervention must occur to have a meaningful impact on the atopic march. While some data on dupilumab and early skin care are encouraging, definitive answers have not been established. 

Dr Del Rosso acknowledges the difficulty in balancing the immediate concerns of parents with the long-term goals of preventing atopic comorbidities, given the lack of long-term studies. However, both he and Dr Swanson agree that early and aggressive management of AD is essential, even if the full extent of its benefits is not yet fully understood. 

Key takeaways 

1. Early intervention is crucial: Treating AD early, particularly in young patients with a family history of atopy, is key to mitigating the atopic march. 
2. Skin barrier care matters: Educating parents about the importance of maintaining the skin barrier with appropriate products is foundational. 
3. Consider systemic therapies: Dupilumab may reduce the burden of AD and potentially prevent or mitigate other atopic conditions 
4. Communication is key: Dermatologists must navigate conversations with parents to address misconceptions, build trust, and emphasize the importance of managing AD thoroughly