Persistence in Atopic Dermatitis

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

About the Author: Dr Marvin Rapaport, MD

In 1978 I initiated and set up the contact and photo dermatitis clinic at UCLA. There was a need to evaluate a large group of patients who exhibited severe eczematoid rashes, especially on the face. Patients were referred from all over Southern California. All patients underwent a lengthy history and examination. Further evaluations included blood studies, allergy patch testing, special sunlight (photo) testing and skin biopsies. From the start it was apparent that most patients experienced a mild dermatitis on various parts of the body that progressively worsened. Their histories always included numerous doctor visits, multiple physicians, and therapy consisting of an increasing amount of corticosteroids. My testing failed to reveal any specific culprit chemicals, cosmetics, perfumes, workplace or recreational exposures. It became increasingly clear that the physician’s therapy, the corticosteroids, was invariably causing the problem. I wrote 7 scientific articles that were published in the most august peer-reviewed dermatologic journals and I gave many lectures at various dermatology meetings. To this day an unfortunate reluctance exists on the part of most physicians to accept this simple concept.