Managing AD Innovations, Challenges, Care Strategies at SDPA
At the SDPA’s 22nd Annual Fall Dermatology Conference, Matthew Zirwas, MD, spoke to attendees about atopic dermatitis, itch, and contact dermatitis.
His first lecture was called “Managing Atopic Dermatitis: Innovations, Challenges, and Care Strategies.” The goal of the lecture was for attendees to leave understanding how atopic dermatitis research has dramatically changed over the last five years.
Dr. Zirwas started the lecture discussing the pathophysiology of itch and how there is not an easily available treatment for just itch.
“Itch is a unique sensation,” Dr. Zirwas said. “It is a specific thing with specific neurons. It is not some type of pain.”
He finds the most interesting thing about itch is that when you scratch it, it’s an “intensely pleasurable sensation.”
“Whenever they put people in an MRI brain scanner, functional MRI, and give them an itch and let them scratch it, it is indistinguishable from giving them cocaine,” Dr. Zirwas said.
Lecturing on the skin conditions surrounding itch is something Dr. Zirwas is passionate about. The fact that for nearly 7 years there have been great treatment options available but 2 million out of the 2.5 million people suffering from moderate-to-severe atopic dermatitis are not on advanced systemic therapy treatments leaves him examining where providers are going wrong.
He broke down the two theories behind this.
“One of the theories is therapeutic inertia, which is basically saying that we as dermatology providers are too dumb to be able to figure out who's suffering enough that they need an advanced systemic therapy,” Dr. Zirwas told Practical Dermatology. “Or maybe we're not too dumb, but we just don't care enough. That, to me, is a ridiculous answer, and I am stunned on a regular basis that people are pushing this as the reason.”
The second theory, which he said has “really good” supporting data, is that providers are “terrible at making the diagnosis.”
“In fact, the data now confirms we are misdiagnosing two-out-of-three people with atopic dermatitis,” Dr. Zirwas said.
He credits the reasoning behind misdiagnosing to outdated diagnostic criteria. The Hanifin and Rajka criteria, he said, “are just dead wrong, and now we have the data to back this up.”
“The data has now shown that the majority of people with adult atopic dermatitis do not have it flex early, and the majority of them do not have atopic comorbidities,” Dr. Zirwas said. “Those diagnostic criteria should be thrown out whenever we’re talking about adults.”
Throughout the lecture, he explained three well-established environmental causes of atopic dermatitis and described how atopic dermatitis differs from pediatric atopic dermatitis and rationally select the best systemic therapy for each individual patient.