Considerations for managing elderly patients with atopic dermatitis

ABSTRACT

Introduction

Atopic dermatitis (AD) diagnosis in elderly is challenging, due to its clinical polymorphism and the lack of diagnostic biomarkers. Moreover, the chronicity of the disease and the complex pathogenetic mechanism, make elderly AD management challenging.

Areas covered

A narrative review of the current literature was performed using the PubMed, Medline, Embase, and Cochrane Skin databases, by researching the following terms: ‘atopic dermatitis,’ ‘clinical phenotypes,’ ‘eczema,’ ‘elderly patients,’ ‘elderly type atopic dermatitis,’ ‘eczema clinical presentation.’ The aim was to report the current knowledge on pathogenesis, clinical presentation, and treatment options of elderly AD.

Expert opinion

Elderly type AD has recently been identified as a separate entity, with an increasing prevalence. With aging, both immunosenescence and barrier alterations can cause or modify AD presentation. Moreover, a chronic proinflammatory state (so-called ‘inflammaging’) is often present in elderly subjects. Older patients with AD may present with peculiar immunophenotypic profile, making AD diagnosis challenging. Similarly, the chronicity of the disease and the complex pathogenetic mechanism, make AD management a challenge. Indeed, systemic therapies for AD are often contraindicated or not tolerated and the management of elderly type AD is often burdened with numerous difficulties, leading to undertreated disease. Even if dupilumab and tralokinumab represent a valuable therapeutic weapon, more data on safety of JAK inhibitors are required.

KEYWORDS:

• Atopic dermatitis
• clinical features
• elderly
• pathogenesis
• therapies

Article highlights

• Elderly type AD has recently been identified as a separate group of patients with peculiar clinical, phenotypic, immunophenotypic, and therapeutic characteristics.

• AD diagnosis in elderly is often challenging, mostly relying on the morphology of skin lesions, clinical course over time, and personal and family history of atopy. Skin biopsy in patients with atypical phenotypes may be mandatory for the differential diagnosis.

• The chronicity of the disease and the complex pathogenetic mechanism, make AD management a therapeutic challenge. Moreover, numerous comorbidities and polypharmacotherapy may strongly impact on management decision.

• Systemic therapies for AD are often contraindicated or not tolerated and the management of elderly type AD is often burdened with numerous difficulties, leading to the risk of an undertreated disease with psychological and physical consequences.

• The efficacy and long-term safety of dupilumab and tralokinumab in controlling clinical manifestations in the absence of side effects represents a valuable therapeutic weapon in the treatment of elderly AD patients. Conversely, more data on safety of JAK inhibitors on elderly type AD are required in order to offer these patients a tailored-tail management.

Declaration of interest

M Napolitano acted as speaker, consultant and/or advisory board member for Abbvie, Eli Lilly, Leo Pharma, Novartis, and Sanofi. C Patruno acted as investigator, speaker, consultant, and/or advisory board member for AbbVie, Amgen, Eli Lilly, Leo Pharma, Novartis, Pfizer, Pierre Fabre, and Sanofi. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosure

One reviewer has participated as PI/SI, advisor and invited speaker for Sanofi, Leo-Pharma, Abbvie, Pfizer, Lilly, Galderma. The remaining reviewers have no other relevant financial relationships or otherwise to disclose.

Author contribution

M Napolitano: data curation, formal analysis, investigation, visualization, supervision, writing-original draft preparation, writing – review & editing. L Potestio: data curation, formal analysis, investigation, visualization, writing-original draft preparation. M Nocerino: data curation, formal analysis, investigation, visualization, writing-original draft preparation. C Patruno: data curation, formal analysis, investigation, visualization, supervision, writing-original draft preparation, writing – review & editing. All authors read and approved the final version of the manuscript.

Additional information

Funding

This paper was not funded.