[Medical Insight 59th] The symptoms and treatment of "atopic dermatitis" that a dermatologist tells us.

□ Broadcast Date and Time: November 22, 2024 (Fri) 10:20 pm
□ Producer in charge: Lee Siwoo
□ Author in charge: Kim Bae-jeong and Kim Hyun-jung
□ Cast: Lee Dong-hoon (Dermatologist at Seoul National University Hospital)
□ Broadcast channel
IPTV - GENIE TV No. 159 / BTV No. 243 / LG Uplus No. 145
SkyLife Number 90
Cable - Delive No. 138 / Hyundai HCN No. 341 / LG HelloVision No. 137 / BTV Cable No. 152

* The text below may differ from the actual broadcast content, so please check the broadcast for more accurate information.


◆ Lee Dong-hoon: Hello, I'm Lee Dong-hoon, a dermatologist. The story I prepared today is symptoms and treatments for patients with itching, moderate or higher atopic dermatitis that they can't stand.

◇ Voice actor Park Sang-hoon: Atopic dermatitis, a chronic inflammatory skin disease accompanied by itching, rash, and dryness. As of 2022, there are about 970,000 patients with atopic dermatitis in Korea, with 3% of the total adult population and 10% of the pediatric population suffering from atopic dermatitis. atopic dermatitis caused by weakened skin barrier due to hypersensitivity reaction of the immune system. More than 80 percent of patients with moderate or higher atopic dermatitis suffer from itching, and more than 40 percent of all patients feel anxiety and depression. Let's take a closer look at the symptoms and treatment of atopic dermatitis, a typical chronic skin disease that lowers quality of life.

<Understanding Diseases>
◆ Lee Dong-hoon: Before I talk about atopic dermatitis with moderate or higher symptoms, I would like to talk about atopic dermatitis first. Atopy means 'weird' and 'inappropriate'. This will make it easy for allergic reactions to food or inhalant substances. Then today's topic is atopic dermatitis. What kind of disease is atopic dermatitis? Atopic dermatitis is basically very itchy. It will be chronic allergic skin inflammation accompanied by very severe itching on the skin. And it's very common. When we usually diagnose by a doctor, it is known that 1 in 10 children and 3 percent of adults. But in the past, I thought that this atopic dermatitis was a child's disease. So I thought it would get better with age, but according to recent studies, especially severe atopic dermatitis patients, these adult atopic dermatitis patients will be one in four new patients in adulthood. In fact, the number of patients with atopic dermatitis is on the rise due to changes such as Western habits and Western diets. Every year, about a quarter of children in Asia are diagnosed with atopic dermatitis.

<Causes of Disease>
◆ Donghun Lee: So why do these atopic dermatitis occur? Basically, genetic factors are known, and environmental factors that I mentioned earlier are known. A typical genetic factor is a component called 'filagreen' that constitutes the skin barrier. In fact, about 40 to 50% of these atopic dermatitis patients in Northern Europe will have Pilagreen mutations. Fortunately, however, less than 10% of these filaggrin mutations are known in Korea, and some of these genetic predispositions are supposed to be small. And the most important cause of atopic dermatitis is basically these skin barriers. We make up the skin and the skin barrier function that prevents any external allergens or irritants from coming in will be impaired, and in this process, external irritants and allergies will enter our skin and cause various immune responses to cause abnormalities, which will increase the itchiness and cause some patients to scratch again, which will further damage the skin barrier function. We call this a vicious cycle of atopic dermatitis. To tell you more about genetics, not all patients actually have genetic predisposition, but about 70 to 80% have a family history of atopic diseases such as asthma and allergic rhinitis, including atopic dermatitis as mentioned earlier. If one of the parents has atopic dermatitis, about one and a half of the children may have atopic dermatitis, and if both parents have atopic dermatitis, it is known that 80% of the children have atopic dermatitis. In addition, about 80% of identical twins have atopic dermatitis together, and about 20% of identical twins can have atopic dermatitis together, so you can see that this is a disease with genetic predisposition.
But there are a number of environmental factors. Recently, as climate change has become very severe, summer has become longer and it is called very wet heat. So, there were many atopic dermatitis patients who got very bad this summer as the weather got hot, humid, and sweat a lot. In fact, you will receive a lot of environmental factors such as humid or hot environments and in-between seasons. Also, when I become an adult like this, the most allergic substances in Korea will become house dust mites. If you are allergic to these house dust mites, if there are more house dust mites due to some environmental factors around you, it can act as a very deteriorating factor. In addition, there may be cases of allergies to various foods in these children's age groups. In addition, atopic dermatitis will be a factor that worsens a lot for various skin irritations, infections in some cases, stress, mental factors, and pollutants such as fine dust that I mentioned earlier.

<Symptoms of Disease>
◆ Lee Dong-hoon: So what kind of symptoms do atopic dermatitis actually show? It is well known that atopic dermatitis has a wide variety of symptoms for each of these age groups. Usually, it occurs in areas where we are stimulated a lot. When a child is young, we call it Taeyeol. Therefore, atopic dermatitis usually occurs in people under the age of two or three months after the age of one. It usually appears on both cheeks or around the mouth where you keep rubbing your cheeks or drooling, and these red spots or convex spots on the skin may come up, and in some cases, dirt or scabs may occur. Not only your face, but when you're young, you crawl around like this. So the parts that touch the floor. You can see that atopic dermatitis easily appears in such disparities as legs and arms. However, when you are this young, there are cases where it appears a lot as an acute lesion. As we get older, this will become a chronic lesion that becomes a little thicker as it takes more time to scratch and the itching becomes chronic. After the age of two, these acute lesions will become increasingly chronic, and the itching will continue, making the skin thicker and the area slightly changed. That's why it's called the face, neck, and folding parts. Now, I think it has some effect on sweat, but there are cases where atopic dermatitis appears severely in these arms and legs, and even if these areas are reduced, there are many cases where these lesions remain or are severe in exposed areas such as the face, neck, and hands, so it will actually have a great impact on the quality of life.

<Diagnosis of the disease>
◆ Lee Dong-hoon: So how do we diagnose these atopic dermatitis? Of course, in a very typical case, it would be easy to diagnose like this just by looking at it once, but the atopic dermatitis society has actually announced these diagnostic criteria, so I'll briefly tell you. I told you earlier that itching is very important. Itching will be a characteristic of atopic dermatitis in almost 100% of patients. In addition, the shape and distribution of the characteristic lesions mentioned earlier are known to appear in areas where the face and limbs crawl under the age of 2, and in areas such as the face, neck, folding, and hands over the age of 2. If you have such an atopic disease in the past, or if you have a family history or a family history, we call it a dog. In fact, if two of these three are satisfied, we can diagnose atopic dermatitis first. In addition to these address dogs, there are a lot of us in 14 types. There is a standard called these sub-opinions. If four of these findings are satisfied, we can diagnose atopic dermatitis again. My skin is very dry when I see a patient with atopic dermatitis. So, there may be a lot of dead skin cells and there may be some cases where the skin is cracked. You may have dry skin around your eyes, ears, lips, hand and scalp dandruff, as well as nipple eczema in adolescence. Also, because it is irritating when you sweat like this, it itch and then atopic symptoms appear on the skin, so when you take an Ige (immunoglobulin E), which is called a skin prick test, you will see an increase in Ige (immunoglobulin E) when you take a blood test. In addition, due to the lack of a skin barrier, the sensitivity to these skin infections increases, and skin infections occur frequently is one of the sub-positions. In addition to that, if we actually see patients with atopic dermatitis, we can see that the color that looks a little white and has uncertain boundaries falls out. This will also be one of the negative findings caused by the loss of melanin cells' function due to inflammation.

<Criteria for moderate or abnormal diagnosis>
◆ Lee Dong-hoon: Then, I'm going to tell you about a moderate or higher level today. Here, the term "moderate" or higher means "moderate" or "severe". In this case, atopic dermatitis patients are really having a hard time with a lot of quality of life. Then, what criteria will be used when evaluating atopic dermatitis above moderate? The most commonly used is EASI (Erhesive Area Severity Score), that is, the eczema area severity score. This "EASI" is a score that comes out by calculating the area and severity of various faces, bodies, arms, and legs, starting with 0 when there is nothing. A score of 16 or higher will result in moderate or higher atopic dermatitis, and a score of 23 or higher will result in severe atopic dermatitis. Along with this, what is commonly used is the evaluation of itching. If the most itchy thing of the day is 0 and the most severe itching you can imagine is 10, we can think of it as very severe itching if we are 7 or more.

<Symptoms of moderate or higher>
◆ Lee Dong-hoon: So what kind of difficulties do some patients with moderate or higher symptoms have? In fact, there are many patients with atopic dermatitis around us, but not many patients with moderate or higher atopic dermatitis may have seen it. In fact, most of these patients were not able to come out until relatively recently and were actually staying at home and not having a very social life. In fact, four out of five patients with moderate or higher atopic dermatitis have a significant impact on their quality of life, and about 15% of patients are known to be treated for eye problems such as cataracts and glaucoma as well as atopic dermatitis. I don't know if you've actually experienced itching. Ninety-one percent of patients with atopic dermatitis experience at least one itching per day. In addition, 60% of patients have severe itching or are difficult to bear. It's 24 hours a day, right? Among them, patients who itch for more than 18 hours account for about 40%. In addition to itching, about 80% of patients complain of moderate or higher pain. If you itch like this, you'll be very uncomfortable not only in your real life but also when you sleep at night. In fact, 55% of patients are five to seven days a week, every day. You will have a sleep disorder every day, and 85% of patients will have difficulty falling asleep due to itching and will wake up in the middle. In the event of a deterioration, more than half of the patients will avoid going out in these public places, and in fact, about 43% of the patients will have severe depression or anxiety, and the likelihood of suicide attempts actually increases significantly.

<Cure of moderate or higher>
◆ Lee Dong-hoon: Then I'm going to talk about how to treat atopic dermatitis. There are three main principles of treatment. Avoidance therapy to avoid exacerbation factors, such irritants and allergic factors. Next, it will be a skin moisturizing treatment with an appropriate bath and moisturizer, and finally, medication to control the itching and inflammation of atopic dermatitis. Since atopic dermatitis is a very heterogeneous disease, customized treatment accordingly is important because there are many differences in symptoms and progress depending on each patient. I mentioned earlier that itching is present in almost all patients with atopic dermatitis. In fact, even when a recent survey of atopic dermatitis patients in Korea was conducted, the most important goal for treatment was to improve itching. Previously, I thought that even if only 75% or 50% of these overall symptoms improved, it would be a great improvement. Also, for itching, we usually call it 0 for things that are not itchy at all, and 10 for things that are too itchy to bear. They said that if these things improve by about four levels, it is a very significant improvement in itching. And in fact, with the recent introduction of many of these effective treatments, there are many cases where these goals are achieved. Then I'll tell you more specifically how we can treat it according to these treatment goals. Of course, basic treatment is very important. It will be a very basic treatment to avoid the deterioration factors mentioned earlier, such as moisturizers and baths, and to follow these overall treatments well through education. Local treatment is also fundamental. In particular, for patients with severe moderate or severe symptoms, non-steroidal topical drugs such as topical steroids or topical calcineurin inhibitors can be used appropriately to improve inflammation. Unfortunately, not all of these basic treatments or topical treatments work for patients with moderate or severe symptoms. So next time, we can do more professional treatment. Phototherapy and other representative immunosuppressants like cyclosporine and methotrexate. We can use those medicines to manage these atopic dermatitis patients. Of course, when we use drugs such as cyclosporine or methotrexate, it is very effective and there are patients who are good. In fact, if you use these medicines for a long time, there are people who are affected by various blood pressures or kidney effects, so it will be a little difficult to use them continuously for a long time. Also, some steroid medications and injections can be used for a while when they get really bad, but long-term use of this can cause various sugar levels, osteoporosis, and other unpredictable side effects, so these immunomodulators that have been used for a long time have actually been avoided as long as possible. However, with the recent introduction of highly effective targeted treatments, we have achieved a higher goal of treatment. That is, there are few of these skin lesions, and this would improve the EASI by more than 90%. We also aim for EASI 90, which refers to improved conditions to any potential inflammation inside the skin, and a higher treatment goal that we achieve with little or no itching. So, through this, the risk of worsening and recurrence of atopic dermatitis will be reduced, and it also aims to keep patients with severe atopic dermatitis in a more optimal state.

<Targeted treatment for moderate or higher>
◆ Donghun Lee: So what are some targeted treatments that are used for patients with moderate or higher severity? Recently developed medicinal ingredients can be classified into two main categories. One is a biological agent, and the other is an oral drug called a JAK inhibitor. Biological agents are antibody treatments that combine individual substances that mediate inflammatory reactions to become drugs that almost completely eliminate the function of these substances. On the other hand, JAK inhibitors will be medications that partially and reversibly regulate the signals of various inflammatory pathways in atopic dermatitis, but very strongly. So what's the difference between biological agents and JAK inhibitors? Biological agents will basically be injections. You will get it every two weeks or, in some cases, every four weeks. Due to the nature of the injection, these biological agents will have relatively fast and long-lasting effects. However, in some cases, side effects such as conjunctivitis and facial erythema may occur. On the other hand, JAK inhibitors are medicine to be taken, and if necessary, it will be possible for us to use it consistently in the long term, regardless of what short-term use. In addition, it shows a very fast effect when complaining of such severe itching and symptoms, so people who want to improve quickly can have a faster effect and a better effect when they have severe atopic dermatitis in exposed areas such as the face, neck, and hands. However, blood tests are needed, and in some cases, side effects such as simple herpes and acne may occur. So we talked about biological agents and recent targeted treatments called JAK inhibitors. One of the things that patients ask a lot is that there are cases where the age of use is set among these targeted treatments. Then, there are people who are asking if the younger the age of insurance coverage, the more it is related to safety. However, this insurance age actually determines the indication of atopic dermatitis by 'whether clinical trials have been conducted or not in various age groups', and some of the JAK inhibitors have been approved by children in other indications and can be used in children. Therefore, it is better to decide after consulting with a specialist doctor, considering the characteristics of a patient or comorbid diseases. Another thing you're saying is that if you keep taking these JAK inhibitors, you might be resistant to them. These JAK inhibitors are completely different from steroids, and they will be completely different from previous drugs like cyclosporine and methotrexate. In addition, since it is not a protein, it is a small molecule substance, so there is no risk of resistance because this immune response or antibody does not occur. In addition, as a result of this meta-analysis and meta-analysis of a large number of people, there have not been any increase in side effects that we may be concerned about, so it is very important to consult with your doctor and use them steadily.

<Medical AI Q&A>
◆ Lee Dong-hoon: Viewers have sent a lot of questions about the symptoms and treatment of atopic dermatitis. Let's check it out together.

◇ Y-GO (AI Anchor): A woman in her 30s. I've been using steroid ointment for the past three years and my skin is burning and getting sick because of the continuous in-between seasons. What kind of treatment should I get in this case?

◆ Lee Dong-hoon: If it gets worse like this, there are many different possibilities for a wide variety of reasons. In fact, when there are many bacteria, antibiotic treatment may be needed for a short period of time. However, if you get hot and sick in a very wide range, you can control it sufficiently and prevent this acute exacerbation by using the recently developed targeted treatments as well as the basic immunomodulatory drug treatment I mentioned earlier.

◇ Y-ON (AI Anchor): What are some foods that help and harm patients with atopic dermatitis?

◆ Lee Dong-hoon: Basically, if we say food that is helpful for atopic dermatitis patients, I think we can tell you about supplements or something. If you look at our Ato Dermatitis Society's guidelines, you can see vitamin D, palm oil, and some probiotics. That is, lactobacilli. Those things can be a little helpful. However, depending on the person, the effects and such may be a little different, so it would be better to consult with your doctor to use it. In the case of harmful foods, there may be cases where food allergies are accompanied, especially when you are young or your reaction decreases a little even when we receive proper treatment. However, if you restrict food unconditionally like this, you don't have to limit it, and because it can cause growth problems or other problems, it is necessary to limit only foods that are related to certain symptoms through various blood tests, tests, and actual food records.

<Let's just remember this>
◆ Lee Dong-hoon: Atopic dermatitis is not a incurable disease. With proper care and treatment, dermatitis and itchiness can be controlled to lead a better life. Sometimes, there are patients who stop treatment because they are misled by folk remedies and visit hospitals in a more severe condition. We ask you to find personal and individual treatments that suit you with a specialist. I hope my story today helped you all live a healthy life. Thank you.