November 17, 2016
Bruce H. Thiers, MD
c/o Detra Davis, Managing Editor
Journal of the American Academy of Dermatology
930 E Woodfield Rd
Schaumburg, IL 60173
Re: Persistence of Atopic Dermatitis
To the Editor:
In the recent article “Persistence of Atopic Dermatitis” (Simpson et al – JAAD Oct 2016 V75 N4 p681-687) an analysis of multiple studies and papers from numerous authors discusses the “persistence of AD” with no mention of clinical patterns, therapy used, or symptomatology of the patients.
Rook’s Textbook of Dermatology (1968) (1) describes the clinical presentation and pathology stating, “Itching is the cardinal symptom, the lesions consist of discreet papules (prurigo), half the cases clear up by the age of 18 months, the childhood phase typically involves the flexures of the elbow and knee, lichenification is common, the adult phase manifests itself as essentially similar to that in later childhood with lichenifications in the flexitures, atopic erythoderma is very uncommon.”
In my experience (2) with both children and adults who have ongoing persistent eczema-like eruptions they exhibit:
- Wide spread red papules
- Symptoms of burning skin
- Skin pain
- Generalized erythema
- Edema and skin oozing
- Repeated flares of redness interspersed with totally normal skin periods
- Spongiosis on biopsy
- Suppression occurs with steroids but symptoms get progressively worse.
None of the above symptomatology is mentioned in Rook’s Textbook of Dermatology. Has the clinical presentation and pathology changed in the last 60 years? I don’t think so. I strongly suggest there are two discrete conditions. Herrick and Tyson stated that “fashion in therapy may have some justification; fashion in diagnosis has none” (3)
Sir William Osler said, “Listen to your patient. He is telling you the diagnosis.” The parents and patients tell you that the disease is getting worse despite more than adequate appropriate therapy which invariably is the use of topical and or systemic steroids. I suggest that “bad or chronic eczema” is in reality corticosteroid addiction with erythema called Red Skin Syndrome (RSS). Atopic dermatitis burns itself out if it is not treated with ongoing corticosteroids. We have prolonged and exacerbated the problem of Atopic Dermatitis with our misguided therapy of ongoing steroids that has resulted in a large population of patients being addicted to steroids and suffering needlessly with Red Skin Syndrome. Fortunately, every one of these patients can be cured by complete and total cessation of the steroids. They absolutely do not need new and “improved” drugs – in fact they are contraindicated.
Bibliography: Persistence of Atopic Dermatitis:
- Rook, A, Wilkinson, D, Ebling, F, Textbook of Dermatology, Blackwell Scientific Publications, 1968, pgs 419-435
- Rapaport M, Rapaport V., The Red Skin Syndromes; Corticosteroid Addiction and Withdrawal. Expert Rev. Dermatol., 2006;1(4):547-561.
- Herrick, W.W. & Tyson, T.L.: Gout (1936) Am. J. Med. Sci., 192;483