Vol. 27. No. 2


This issue of Seminars in Cutaneous Medicine and Surgery is dedicated to atopic dermatitis. Atopic dermatitis is one of the most prevalent skin diseases found in dermatology practices, and these patients are often uncomfortable, sleep poorly, and are frustrated with their disease and the available treatment options. Many experiment with multiple conventional and unconventional treatments in search of the “cure.” While our patients struggle to manage their disease, we strive to take better care of them by remaining up-to-date on advances in clinical and basic science research and their application to our practices. To further those efforts, my goal as editor of this issue was to include a balance of clinically relevant basic science and practical clinical issues related to atopic dermatitis. The contributing authors for this issue are an esteemed group of clinicians and scientists. Dr. Alan Irvine and colleague Sara Brown lead with their comprehensive review on the association of the filaggrin gene mutations with atopic dermatitis. This finding has been one of the most written about and researched topics in atopic dermatitis in the past several years, and we remain hopeful that this finding will lead to new therapies. Dr. Jeffrey Sugarman authored the review of the epidermal barrier abnormalities in atopic dermatitis. The discovery of barrier defects has greatly impacted our daily practices and feeds a growing market of repair products. We hope that barrier repair will help stop the “atopic march,” therefore, preventing future morbidity from other atopic conditions. Dr. Tissa Hata and Dr. Richard Gallo thoroughly review the role of antimicrobial peptides and skin infections in atopic dermatitis, and Dr. Elif Dokmeci and Dr. Christina Herrick stress the importance of the immune system in atopic dermatitis in their manuscript. Dr. Boguniewicz and colleagues provide an exciting window into their multidisciplinary clinic developed at the National Jewish Medical and Research Center. The problems and “roadblocks” many of us face treating patients with severe atopic dermatitis could be solved with this type of structured program, and I applaud their commitment to this patient population. Dr. Andrew Krakowski and Dr. Magdalene Dohil have written a pediatric dermatologist’s approach to appropriate topical therapy for children with atopic dermatitis and have provided a primer on wet wrap therapy. Many parents of children with atopic dermatitis want to know if their child’s atopic dermatitis is caused by a food allergy. Dr. Kim’s article will help the practicing dermatologist navigate this controversial topic. Finally, Dr. Arash Akhavan and Dr. Donald Rudikoff provide a review on the use of systemic immunosuppressive therapy in atopic dermatitis patients. It has been a pleasure to work with this group of expert authors. Their contributions contain thorough and relevant information that we hope will be useful to both practicing dermatologists and scientists.

The Epidermal Barrier in Atopic Dermatitis

Jeffrey L. Sugarman, MD, PhD

Epidermal barrier function is abnormal in individuals with atopic dermatitis (AD). It is
controversial whether primary epidermal barrier abnormalities alone account for the physiological
and clinical abnormalities found in those persons with AD or whether the observed
barrier dysfunction is a consequence of primary immunologic abnormalities. Recent evidence
is strengthening the argument for the former hypothesis. Attention to epidermal
barrier care (ie, gentle skin care) has long been an important part of the therapy of AD.
Advances in our understanding of the biology of the epidermal barrier and how this relates
to the clinical manifestations of this disease has important consequences for new therapeutic
approaches in the management of AD.
Semin Cutan Med Surg 27:108-114 © 2008 Elsevier Inc. All rights reserved.


A Multidisciplinary Approach to Evaluation and Treatment of Atopic Dermatitis

Donald YM Leung, PhD | Kim Kelsay, MD | Mark Boguniewicz, MD | Noreen Nicol, MS, RN, FNP

Atopic dermatitis is a common, complex disease that frequently follows a chronic, relapsing
course. The disease can impact the quality of life (QOL) of patients and families to a
significant degree. Patients and caregivers may focus on unproven triggers at the expense
of proper skin care. A multidisciplinary approach is needed to comprehensively evaluate
triggers and response to treatment, address confounding factors including sleep disruption,
and educate patients and caregivers.
Semin Cutan Med Surg 27:115-127 © 2008 Elsevier Inc. All rights reserved.


Atopic Eczema and the Filaggrin Story

Alan D. Irvine, MD, FRCPI | Sara J. Brown, MBChB, BSc, MRCP

The discovery that null mutations in the filaggrin gene (FLG) are associated with atopic
eczema represents the single most significant breakthrough in understanding the genetic
basis of this complex disorder. The association has been replicated in multiple independent
studies during the past 2 years with the use of various methodologies, from populations in
Europe, the United States, and Japan. Filaggrin plays a key role in epidermal barrier
function, and its association with atopic eczema emphasizes the importance of barrier
dysfunction in eczema pathogenesis. This review aims to summarize the current state of
knowledge regarding the role of FLG mutations in ichthyosis vulgaris, atopic eczema, and
other skin disorders, with an emphasis on potential clinical applications. Further research
is needed to clarify the precise role of filaggrin in skin and systemic atopic disease, to pave
the way for novel therapeutic interventions.
Semin Cutan Med Surg 27:128-137 © 2008 Elsevier Inc. All rights reserved.


The Immune System and Atopic Dermatitis

Christina A. Herrick, MD, PhD

Atopic dermatitis (AD) is a chronic inflammatory skin disease with a complex pathogenesis.
It is clinically well-defined and represents one manifestation of the atopic state, along with
asthma, food allergy and/or allergic rhinitis. Within the last several decades, there has been
much evidence to support the contribution of immune mechanisms in the pathogenesis of
AD. It has also been documented that the prevalence of all atopic disease, including AD,
has been increasing, although the environmental factors that may be contributing to this
increase are not clearly defined. A better understanding of the underlying immunopathogenesis
of AD should aid in better clinical management and development of new treatment
Semin Cutan Med Surg 27:138-143 © 2008 Elsevier Inc. All rights reserved


Antimicrobial Peptides, Skin Infections, and Atopic Dermatitis

Ricard L. Gallo, MD | Tissa R. Hata, MD

The innate immune system evolved more than 2 billion years ago to first recognize
pathogens then eradicate them. Several distinct defects in this ancient but rapidly responsive
element of human immune defense account for the increased incidence of skin
infections in atopics. These defects include abnormalities in the physical barrier of the
epidermis, alterations in microbial pattern recognition receptors such as toll receptors and
nucleotide binding oligomerization domains, and a diminished capacity to increase the
expression of antimicrobial peptides during inflammation. Several antimicrobial peptides
are affected including; cathelicidin, HBD-2, and HBD-3, which are lower in lesional skin of
atopics compared with other inflammatory skin diseases, and dermcidin, which is decreased
in sweat. Other defects in the immune defense barrier of atopics include a relative
deficiency in plasmacytoid dendritic cells. In the future, understanding the cause of these
defects may allow therapeutic intervention to reduce the incidence of infection in atopic
individuals and potentially decrease the severity of this disorder.
Semin Cutan Med Surg 27:144-150 © 2008 Elsevier Inc. All rights reserved.