– What is atopic dermatitis?
– This is a genetically determined disease called allergic skin diseases. It is characterized by a chronic recurrent course and the spread of the lesion over the entire surface of the skin, weeping, often severe due to infection; patients experience very severe itching, their sleep is interrupted, their ability to work is often lost, the disease significantly worsens their quality of life.
Each era has its own localization features. If these are infants, in older children folds, extensor surfaces, face are affected – flexion surfaces, as well as folds, face. We usually see an acute process that occurs with the phenomenon of crying in childhood.
Atopic dermatitis in adults already follows a chronic course, which proceeds somewhat differently. Their skin has changed significantly, has a rough appearance with an enhanced skin pattern. All this is accompanied by very pronounced dryness, peeling and severe itching in both children and adults. The peeling is so strong that sometimes after a consultation you can scoop up the exfoliated epidermis.
Is atopic dermatitis related to allergies?
Yes, in 80% of patients. Often allergic rhinitis is combined with bronchial asthma. And in children, this is often accompanied by food allergies. Now more and more people are talking about the combination with eosinophilic esophagitis. This is an inflammation of the esophagus, gastrointestinal tract. The condition manifests itself as infiltration of the epithelium by eosinophils.
Are eosinophils leukocytes?
Yes, it is a type of leukocytes. And in our patients, especially in severe atopic dermatitis, the content of eosinophils in the blood is very high. They can reach 30% at rates of up to 5% – 6% as a percentage. This is a measure of the effectiveness of the process.
What causes atopic dermatitis?
“This is a genetically predisposed disease. It occurs in families where the mother or father has rhinitis, asthma, or atopic dermatitis. The probability of developing an allergic disease, including atopic dermatitis, in a child born in such a family is approximately 75%. I wish mom – 60% probability. I wish dad – about 15%.
In addition, patients with atopic dermatitis have a genetically determined dysfunction of the epidermal barrier due to mutations in certain structural proteins such as filagrin. Such children are born with dry skin, which is exposed to undesirable environmental influences, including allergens.
What percent of people have this mutation?
– It is believed to be about 30%. It is detected in patients with severe atopic dermatitis. But it has already been shown that, in addition to atopic dermatitis, patients with bronchial asthma also have such mutations.
So are there two causes of atopic dermatitis?
“These are not causes, they are prerequisites plus the effect of epigenetic factors, i.e. environmental factors. These are various climatic conditions, allergens, high humidity or vice versa, dryness of atmospheric air, geographical location, dietary habits.
For example, atopic dermatitis in the Negroid or Mongoloid race is different from the Caucasian race. There are certain differences in the immune response and the leading immune cells involved in the development of the disease – immunocytes.
By the way, a severe form of atopic dermatitis is quite common among the Negroid race. And they have more structural protein mutations.
– Will moving to a different climate solve the problem of atopic dermatitis?
– No unfortunately. However, dermatitis can take a different course, which is milder. Remission can occur and can be quite permanent. But suddenly the disease can return again, and no one knows when it will happen.
And there is also such a phenomenon – it is called “swing”. This is when, for example, skin manifestations improve or even disappear, but the condition of allergic respiratory diseases worsens. such as rhinitis and asthma. And there are many such patients. That is, the organ is replaced – the target of allergic inflammation.
What is the mechanism of this disease? What underlies atopic dermatitis?
– This is the so-called T2-dependent disease, which relies on the immune response, T2. T2-related diseases also include other allergic diseases – asthma, rhinitis, food allergies, eosinophilic esophagitis, polyposis rhino-inusitis, etc.
There is now more evidence about the systemic nature of atopic dermatitis – so it’s not just a skin disease. Most patients with atopic dermatitis have allergic comorbidity, that is, such patients can simultaneously have rhinitis, asthma, food allergies, eosinophilic esophagitis, which characterizes the multi-organism of allergic inflammation.
It has been proven that patients with atopic dermatitis are also characterized by the development of concomitant diseases from other organs. For example, they have a high risk of developing cardiovascular disease, which can lead to strokes and heart attacks. They are more likely to develop atherosclerosis.
These patients are characterized by systemic connective tissue diseases such as rheumatoid arthritis and systemic lupus erythematosus. Common problems from the gastrointestinal tract – ulcerative colitis, Crohn’s disease, which is more common in patients with atopic dermatitis than in the healthy population. These patients are also characterized by the development of vitiligo and alopecia and other diseases, and this is confirmed by recent studies.
Are eczema and atopic dermatitis synonymous?
– These are completely different diseases, eczema is treated only by dermatologists. And eczema has nothing to do with atopic dermatitis and allergies.
– There is also the so-called “scrub”. Atopic dermatitis is also confused with them…
– This is completely different. The pruritic (nodular) form of atopic dermatitis can sometimes be confused with nodular prurigo, but a specialist will distinguish it.
– Is there an analysis for this T2 immune response to definitively diagnose “atopic dermatitis”?
— There is no universal analysis. And what can be done is to do an allergic examination. The goal is to identify causally important allergens. This examination is carried out in two ways: either on the patient himself, using skin tests, or using laboratory diagnostics aimed at determining the allergen of certain class E immunoglobulins to various allergens.
These can be inhaled allergens (aeroallergens), for example, house dust mites, pollen from various plants, various fungi – microorganisms. Could be food allergens.
However, the analysis should be done by an allergist. Since patients often come to us with non-case-related test packs. And they say: be kind enough to decipher. And there is nothing to decipher there because the analyzes are inadequate, often not needed at all.
– What do you mean by “inadequate analysis”?
For example, we have long been detecting IgG antibodies against food products for any reason. And IgG antibodies (immunoglobulins G) are unimportant because they are memory antibodies. Patients also bring packs of expensive tests and say, “Doctor, I can’t stand anything.” I explain: “IgG are memory antibodies. And this analysis only shows that you have encountered this product in your lifetime. And in response to acquaintance with this product, IgG antibodies formed.
– There are cases when a person analyzes for a certain range of allergens and receives the answer: No allergy. He’s coming tomorrow, testing the same spectrum in another lab, and he’s allergic to everything. Why could this be?
– Analysis results largely depend on the accuracy and specificity of the test systems used for diagnosis. There are such non-specific and insensitive test systems that it remains to throw such tests in the trash.
Unfortunately, due to geopolitical events, the main companies producing test systems left Russia (although some still remain). Yet we find ways that allow for such analysis not in Russia, but in other friendly countries. It just takes longer and is slightly more expensive. Now that we already have and are developing diagnostic test systems in Russia, we hope that they will be really sensitive and extremely specific.
Is allergen-specific immunotherapy still the main method in the treatment of allergic diseases?
– Yes. It was discovered in 1911 by British scientists Leonard Noon and John Freeman and has been used all over the world ever since. Approaches have not changed, but drugs for treatment have improved.
Now not only subcutaneous allergen-specific immunotherapy is used, but also sublingual preparations (drops under the tongue). Treatment should continue for three years, sometimes 5 years.
Can atopic dermatitis be treated permanently?
– NO. You can only achieve a long-term remission.
However, since 2019, in the arsenal of allergists there is dupilumab, a genetically engineered biological drug with which you can simply achieve revolutionary results. It has made the lives of some of our patients 70%, 80% or even 90% better.
This is a revolutionary medicine that, as they say, divides the patient’s life into “before” and “after”. Patients who take it live a happy and normal life.
– Is it expensive?
– This is a monoclonal antibody, unfortunately such drugs are expensive. You need to make 2 injections per month, which is about 85 thousand rubles.
We allergists fight for the Department of Health to list atopic dermatitis as a systemic disease. This is a lot of money, as the drug must be taken for life. If it is on this list, then patients will be able to receive the drug for free. Our patients are neither able to work nor study – many children are homeschooled. These are really serious patients.
– Spring has come, people with hay fever are starting to choke on pollen. There is an exacerbation of atopic dermatitis. What would you recommend to them?
– As for atopic dermatitis, first of all it is necessary to improve the function of the epidermal barrier. We need special emollients – moisturizers. This period can be transferred much more easily if you use these drugs correctly and beforehand.
Other recommendations are individual. Since the treatment of atopic dermatitis is now personified. You should go to doctor.
– If there are more people with allergies in the world every year, then will atopic dermatitis grow?
– Yes it will happen. We’re even talking about an allergy epidemic now. Because more than 30% of the world’s population suffers from one or another allergic disease. Therefore, atopic dermatitis will unfortunately be more.