Atopic Dermatitis and the Medications Used for its Management: Impact on Ocular Health

May 2022 | Volume 21 | Issue 5 | 523 | Copyright © May 2022


Published online April 25, 2022

Caroline Beakes BS, Leera Briceno MD

South Shore Dermatology Physicians, North Easton, MA

Abstract
Atopic Dermatitis (AD) is one of the most common inflammatory skin conditions. AD is generally characterized by eczematous and pruritic skin lesions, although it can present differently between individuals. There are multiple comorbidities for AD, including asthma, food allergies, and ocular disorders such as conjunctivitis. Common treatments for AD include topical corticosteroids, calcineurin inhibitors, and injectable biologic medications. However, all these medications pose risks that may deter some patients. Ocular risks are associated with use of both topical corticosteroids and biologics, which presents an interesting challenge as ocular risks are also comorbidities for AD itself. We present a case of one patient’s history with severe AD and ocular disorders. Since ocular disorders were of great concern to her, she chose to treat her eczema conservatively with non-steroidal topical medications. Her eczema remained poorly controlled, and she subsequently developed eczema herpeticum. Once recovered from eczema herpeticum, she decided to initiate biologic treatment. With dupilumab therapy, her eczema cleared promptly and revealed to her how much her eczema had compromised her quality of life now that she had accepted the treatment that frightened her for many years.

J Drugs Dermatol. 2022;21(5):523-525. doi:10.36849/JDD.6179

INTRODUCTION

Atopic Dermatitis (AD) is a chronic inflammatory skin condition affecting children and adults of all races and ethnicities.1-3 AD commonly presents with eczematous and pruritic skin lesions. These lesions can contribute psychological and social burdens in addition to physical discomfort.4 AD-affected skin is less able to function as an essential barrier to pathogens; thus, there is increased risk of bacterial, fungal, and viral infection.5 Infection with the herpes simplex virus (HSV) may lead to eczema herpeticum, marked by extensive vesicular eruption within AD-affected skin. Eczema herpeticum, if left untreated, can lead to systemic infection, systemic inflammation, organ dysfunction, and death.6 Furthermore, patients with AD have increased risk of multiple co-occurring conditions, including asthma, food allergies, and various ocular complications.6-7 The ocular conditions include conjunctivitis, keratoconjunctivitis, blepharitis, keratoconus, cataracts, glaucoma, and retinal detachments.7-8 Notably, common treatments for AD have also been associated with ocular side effects.

Cataracts are known to affect between 25 and 50% of adults diagnosed with AD.9-10 Cataracts secondary to AD in children are noted to be rare.9 However, cataracts are reported in adults and children who therapeutically use corticosteroids. Corticosteroid-induced cataracts are associated with intravenous, oral, inhaled, and topical corticosteroid use.9 It is possible that frequent touching and rubbing of the face and eyes by children contributes to topical steroid associated cataracts in children with AD.9

Biologic medications have recently become a staple option in the treatment of moderate to severe AD.11 Biologic medications more specifically target the cellular pathways implicated in the dysregulated immune response that contributes to AD. Dupilumab, approved by the FDA in 2017 for patients with moderate to severe AD, is the first biologic approved in the US for the treatment of AD.12 Dupilumab targets both interleukin (IL)-4 and IL-13 signaling, effectively reducing cytokine-induced inflammatory responses that contribute to the phenotype of AD.12-13 Dupilumab-associated conjunctivitis (DAC) is one of the most commonly reported side effects of dupilumab treatment.12 Patients with moderate to severe AD treated with dupilumab are more likely to develop conjunctivitis than those treated with placebo.14 The severity of conjunctivitis developed in some