Differences in Atopic Dermatitis Presentation Across Age Groups and Skin Types
A panelist discusses how recognizing the diverse presentations and patient demographics of atopic dermatitis—especially adult-onset cases and common mimics like scabies—is essential for accurate diagnosis and management in primary care, with an emphasis on clinical assessment over biopsy and the importance of cultural competence in dermatologic evaluation.
The speaker emphasizes the importance of keeping scabies in mind as a potential mimic of atopic dermatitis (AD), especially since it can be easily misdiagnosed. Beyond morphology, the speaker transitions into discussing the broader context of AD, including epidemiology and patient demographics. In the US, AD affects approximately 13% of children and 7% of adults, with higher prevalence and more severe disease observed in African American and Hispanic populations. While AD commonly begins in childhood, it can also start in adolescence or adulthood, contrary to traditional teachings. In fact, adult-onset AD is not uncommon, and it’s critical to recognize its variability in presentation, persistence, and age of onset.
The severity of AD ranges widely, with the majority of cases being mild to moderate, but moderate to severe cases are more likely to persist long term. Many patients are misled into believing their condition will “burn out” with age, which can lead to frustration if it does not. Commonly affected regions include the flexures, such as the elbows, knees, and neck, although hand involvement is more typical in adult-onset cases. Comorbid allergic conditions are often present, including asthma, food allergies, and, more rarely, eosinophilic esophagitis. Understanding distribution, severity, and patient history plays a key role in differentiating AD from other dermatologic conditions.
Finally, the speaker underscores the need for clinicians to grow confident in making a clinical diagnosis without overreliance on biopsies, which are often nonspecific and can mislead. Instead, careful assessment of lesion morphology, distribution, patient history, and comorbidities should guide diagnosis. While steroid treatment is often a safe empirical choice in inflammatory skin diseases, distinguishing AD from infections is crucial to avoid inappropriate treatment. Clinicians are encouraged to familiarize themselves with a range of dermatologic images across diverse skin types and to consider broader patient and environmental factors, such as racial background and seasonal changes, that can influence presentation.
