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Atopic dermatitis (AD) is a persistent inflammatory skin disorder characterized by two key factors, barrier dysfunction and immune system dysregulation. The condition significantly impacts quality of life and requires a multifaceted approach to management. This case study highlights the treatment journey of a 32-year-old female patient with severe chronic AD, illustrating the transition from conventional topical therapies to systemic treatment and exploring the potential for future management strategies.
Patient Presentation
Ms. Berruyer, a 32-year-old agricultural engineer from Angers, France, has struggled with AD since childhood. Her condition, prevalent in her family, affects her hands, elbows, face, and neck. Despite rigorous adherence to various topical treatments, including corticosteroids and tacrolimus, Ms. Berruyer experienced persistent flares and significant psychosocial distress.
The patient’s daily life was severely impacted by itching, pain, and discomfort, particularly affecting her hands and professional interactions. The COVID-19 lockdown further exacerbated her symptoms, likely due to stress from increased hand hygiene practices.
Clinical Examination and Initial Management
Upon referral to the University Hospital in Angers, Ms. Berruyer was evaluated by Dr. Delaunay on 29 May 2020. The patient presented with chronic eczema localized to her hands, face, and neck, accompanied by moderate severity and significant quality of life impairment. She also suffered from rhino-conjunctivitis due to pollen allergies.
Dr. Delaunay provided an in-depth explanation of AD, including its genetic and immunological components. The management plan included enhanced patient education on the correct use of topical treatments and the introduction of systemic therapy. Given the failure of topical treatments, ciclosporin was chosen as the systemic therapy to manage the patient’s severe symptoms.
Systemic Therapy and Follow-Up
Ciclosporin was initiated to address the inadequate response to topical treatments. The patient showed a significant improvement, with a 75% reduction in eczema lesions within one month. However, after six months, renal side effects emerged, as indicated by elevated serum creatinine levels, necessitating a reduction in ciclosporin dosage.
The long-term treatment strategy includes transitioning to dupilumab, a biological agent targeting the type 2 T-cell pathway, for ongoing management. Additionally, patch testing is planned to investigate potential contact eczema exacerbations, which was deferred while the patient was on ciclosporin due to potential interference with test results.
Discussion
This case underscores the challenges in managing chronic AD, particularly when conventional topical treatments are ineffective. The successful use of ciclosporin highlights the importance of systemic therapies in achieving rapid symptom relief and improved quality of life. The emergence of side effects from ciclosporin emphasizes the need for a strategic shift to long-term management options, such as dupilumab.
The integration of systemic treatments and continuous patient education are crucial for effective AD management. Healthcare professionals must stay updated on the latest therapeutic advancements and provide personalized care based on individual patient responses.
Conclusion
The management of chronic AD requires a comprehensive approach that includes both conventional and systemic therapies. This case demonstrates the importance of individualized treatment plans, ongoing patient education, and adaptability in treatment strategies to optimize outcomes. As new therapies continue to evolve, patients with AD can expect improved symptom control and quality of life.
Link to original article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885759/
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