A Consensus on Staphylococcus aureus Exacerbated Atopic Dermatitis and the Need for a Novel Treatment

October 2024 | Volume 23 | Issue 10 | 825 | Copyright © October 2024


Published online September 30, 2024

doi:10.36849/JDD.8240

Lawrence A. Schachner MD FAAD FAAPa, Anneke Andriessen PhDb, Mercedes E. Gonzalez MD FAADc, Karan Lal DO MS FAADd, Adelaide A. Hebert MD FAADe, Lawrence F. Eichenfield MD FAAD FAAPf, Peter Lio MD FAADg

aDermatology and Pediatrics, Pediatric Dermatology, University of Miami School of Medicine, Miami, FL
bRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands
cPediatric Skin Research, Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine Miami, FL
dAffiliated Dermatology, Scottsdale, AZ; Northwell Health, NY
eDepartment of Dermatology and Pediatrics, McGovern Medical School, and Children's Memorial Hermann Hospital, Houston, TX
fDepartments of Dermatology and Pediatrics, University of California San Diego School of Medicine, San Diego, CA
gDermatology and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL

Abstract
The skin microbiome is essential for skin barrier function because it inhibits pathogen colonization, and decreased microbiome diversity correlates with increased Staphylococcus aureus (S. aureus) burden and atopic dermatitis (AD) severity. Managing S. aureus-driven AD in clinical practice remains problematic due to complications such as AD exacerbation, impetigo, abscesses, and invasive infections. This project used a modified Delphi process comprising face-to-face discussions followed by a blinded vote to define 5 final consensus statements. A panel of 6 pediatric dermatologists developed a consensus on S. aureus-driven AD exacerbation, challenges in current treatments for AD with secondary bacterial infections, and new developments to improve patient care and outcomes. The panel's 5 consensus statements provide recommendations for dermatologists, pediatricians, and healthcare providers treating patients with secondary infected AD. These recommendations underscore the importance of recognizing and managing S. aureus skin infection in AD clinical practice and promoting antibiotic stewardship to mitigate resistance. The panel defined a significant unmet need for a single topical AD therapy effective against all symptoms, including pruritus, S. aureus-driven AD exacerbation, infection, and inflammation, across AD severity levels.

J Drugs Dermatol. 2024;23(10):825-832. doi:10.36849/JDD.8240

INTRODUCTION

Current Clinical Challenges in Atopic Dermatitis Management and Treatment
Despite advances in topical and systemic treatment options for atopic dermatitis (AD), challenges persist in effectively managing the condition, leading to significant disruption to patients and their families.1 AD has the highest global burden among skin disorders, and hospitalizations due to AD flares and related infections are associated with an 8.3-year reduction in lifespan.2-4 In addition, over 60% of adults report severe or unbearable pruritus, and 55% of adults with moderate-to-severe AD experience inadequate disease control.5-7 AD outpatient visits have increased to almost 2 million annually. Dermatologist visits are more frequent for chronic AD, and primary care physician visits are more frequent for acute AD, particularly in pediatric patients under 4 years old.1,8 This highlights the need for improved AD treatment and disease control, especially in pediatric patients, and for the ongoing education of all pediatric healthcare providers.

The skin microbiome is essential for skin barrier function, inhibiting pathogen colonization and modulating immune responses.9,10 The microbiome contributes to immune system development in infants and AD occurrence.9,10 Furthermore, reduced microbiome diversity correlates with increased Staphylococcus aureus (S. aureus) burden and AD disease severity.1,10

S. aureus plays a central role in AD exacerbation, skin colonization, and infectious complications, and managing S. aureus-driven AD remains problematic. Evidence shows that S. aureus is increased with higher AD severity and is associated with infectious complications such as impetigo, cellulitis, abscesses, and invasive infections.11-14 Up to 90%of patients with AD are colonized with S. aureus, often both in lesional and nonlesional skin.15,16 Furthermore, increased S. aureus colonization is linked to microbial dysbiosis and reduction of skin microbiome diversity.10 Indeed, decreased skin microbiome diversity and increased S. aureus
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