Satish DA, Radhika VK

Skin, Cosmetic & ENT Care Centre, Bangalore.

Abstract

A 44 year old male presented with Atopic dermatitis (AD) with onset from the age of 10 years. The dermatitis was severe, generalised and persistent from childhood to adulthood. The patient was also a known asthmatic since childhood. To our knowledge, relatively little has been published on adult AD compared to the body of literature devoted to AD in children. AD in adults usually exists for years, compromising quality of life and occupational choices. The psychosocial and economic burden of the disease can be profound.

Introduction

The word ‘atopy’ comes from the Greek (a-topos: `without a place’). It was introduced by Coca and Cooke in 1923. Atopy is a state in which an exuberant production of IgE occurs as a response to common environmental allergens. Atopic subjects may or may not develop one or more of the atopic diseases such as asthma, hay fever, eczema and food allergies; the prevalence of atopy is suddenly rising.1 We herein report a case of an adult with atopic dermatitis (AD).

Case Report

A 44 year old male, presented with complaints of redness, scaling, thickening and itching on the body since the past 10 years. Present exacerbation was since 2-3 months. The symptoms started initially on the face including eyelids, later spread to the flexural aspect of elbows, knees & subsequently to the trunk.

The patient was a known asthmatic which was under control with β2 agonists (Salbutamol) for the last 20 years. He also complained of frequent episodes of allergic rhinitis. Family history of atopy was present in one parent (father) in the form of asthma. He was not on any other medications for any systemic problems.

On examination, erythema & scaling were noted on the bilateral eyelids, retro auricular areas. Eyelid skin was also lichenified below the infraorbital area due to constant itching. Hyperpigmented lichenified plaques were seen on the ante cubital fossa and popliteal fossa. The dorsa of the hands and feet also showed lichenification.Truncal lichenified plaques were seen. Generalised Xerosis along with palmo plantar hyperlinearity was also present. Patch tests could not be performed as there was persistent dermatitis on the back. He had frequent exacerbations throughout the year, with no remissions during any season.

Laboratory investigations revealed raised Eosinophil counts (Eosinophilia-8%) and raised Immunoglobulin E levels (IgE levels). ESR was also slightly raised. The rest of the parameters were within normal limits.

Based on these findings, a diagnosis of adult atopic dermatitis was made. He was prescribed anti-histamines- fexofenadine 180mg/day and levocetrizine 10mg/day to control the pruritis.Topical liquid paraffin was prescribed as an emollient to be applied twice a day. Aloe vera containing moisturiser cream was given to be applied to the face including the eyelids and retro auricular areas. Mild topical steroid was given to the eczema on the eyes, retroauricular areas, moderate-potent steroid on the hands, feet, elbows and knees. The dermatitis gradually improved over the next few weeks.

Discussion

Atopic dermatitis (AD) is a chronic, pruritic, relapsing and remitting inflammatory dermatoses that affects upto 25% of children and 2% to 3% of adults2.

Bannister and Freeman from Australia described a subgroup termed adult onset AD in 20003 . AD in adults is an important dermatologic disease. AD can present as adult onset AD or as infantile / childhood AD that persists or recurs after many years4. Adult onset AD has a broad range of age at the onset with a peak at 20-40 years of age with a female preponderence5. AD can also have an onset after the fifth decade called the senile onset AD which has a male preponderance.

The characteristic manifestation of adult onset AD is inflammatory eczema with lichenification, affecting the flexures and extensors, hands, shoulders, neck, face and eyelids4. Nummular lesions are the most common non-typical morphological variant in adult onset AD and the other atypical variants include follicular, prurigo-like or seborrheic dermatitis like lesions.

Extrinsic AD is more common in adult onset AD (87.5-93.05%) and the prevalence of intrinsic AD tends to be higher in younger individuals (15-45%) when compared to adults (5.4-12.5%)6.

AD in adults usually exists for years, compromising quality of life and occupational choices. The psychosocial and economic burden of the disease can be profound7.

Conclusion

This case is presented to highlight the not so frequently diagnosed adult atopic dermatitis with onset in childhood. As we should be seeing more adults with AD in the future, there is a need for more clinical and immunological studies in older patients. Else many cases of AD would be missed in adults resulting in being misdiagnosed as unclassified endogenous dermatitis.

References

1. John Hunter, John Savin and Mark Dahl. Eczema and dermatitis:Clinical Dermatology Third Edition 2006 ; 81-82.
2. Eichenfield LF, Tom WL, Chamlin SL, Feldman SR et al. Guidelines of care for the management of atopic dermatitis: Section 1. Diagnosis and assessment of atopic dermatitis. J Am Acad Dermatol. 2014 Feb; 70(2): 338-51.Review.
3. Bannister MJ, Freeman S. Adult- onset atopic dermatitis. Australas J Dermatol 2000; 41 : 225-8.
4. Katsarou A, Armenaka M. Atopic dermatitis in older patients: Particular points. J Eur Acad Dermatol Venereol 2011 Jan; 25(1): 12-8.
5. Tanei R, Katsuoka K. Clinical analyses of atopic dermatitis in the aged. J. Dermatol 2008; 35: 562 -9.
6. Kulthanan K, Boochangkool K, Tuchinda P, Chularojanamontri L. Clinical features of the extrinsic and intrinsic types of adult onset atopic dermatitis. Asia Pac Allergy 2011; 1: 80-6.
7. Ellis CN, Mancini AJ, Paller AS, Simpson EL et al. Understanding and managing of atopic dermatitis in adult patients. Semin Cutan Med Surg. 2012 Sep ; 31 (3 suppl): S18-22. Review.