Proposed Classification Framework for Atopic Dermatitis Unveiled

Doug Brunk

July 16, 2021

The heterogeneous clinical course of atopic dermatitis (AD) and its differing signs, symptoms, burden, and response to treatment can pose a quandary for physicians.

Dr Jonathan Silverberg

This is behind a new classification framework called DESCRIBE-AD, proposed by Jonathan I. Silverberg, MD, PhD, MPH, not only as a way to standardize the assessment of AD in clinical practice – but also to improve the classification of AD in clinical practice and clinical trials, facilitate tailoring of therapy to individual patient characteristics, and better identify therapeutically relevant disease subsets.

Silverberg, director of clinical research in the department of dermatology at George Washington University, Washington, debuted DESCRIBE-AD during the Revolutionizing Atopic Dermatitis symposium. The "D" in the mnemonic stands for dermatitis morphology and phenotype, the "E" for evolution of disease, the "S" for symptom severity, the "C" for comorbid health disorders, the "R" for response to therapy, the "I" for intensity of lesions, the "B" for burden of disease, and the "E" for extent of lesions.

At the meeting, he discussed the concepts behind each letter of the mnemonic.

Dermatitis Morphology and Phenotype

In the dermatitis morphology and phenotype component of DESCRIBE-AD, "there's a lot to consider," he said. "There are chronic signs like lichenification and prurigo nodules, which have treatment ramifications," such as the length of time patients may need to be treated, and possibly "the use of more potent, targeted options to go after some of these lesions."

Recent studies suggest that nummular lesions have a different underlying pathogenesis suggesting an overlap between Th2 and Th17 cell–mediated lesions. "How does that impact response to targeted therapies?" he asked. "We have no idea. We need to learn that." He noted that psoriasiform lesions are not limited to Asian patients, but also appear in elderly patients with AD. "They look different [in elderly patients] and they may respond differently; they have more psoriasiform lesions and it's not exactly clear why."

Other morphologic variants of AD to be aware of include follicular eczema, xerosis, and the itch-dominant form, which Silverberg and colleagues addressed in a recently published study. "There are some patients who have milder-looking lesions, but their itch is just out of control," he said. "This is a pattern that we need to recognize."

Evolution of Disease, Symptom Severity

Factors to consider for the evolution of disease component of the proposed classification include age of AD onset or disease recurrence, frequency and duration of flares, disease activity between flares, periods of disease clearance, and the overall disease trajectory. "We do get patients who say that every year their disease seems to get worse over time, for reasons that are not always clear," Silverberg said.

Assessment tools he recommends for the symptom severity component of DESCRIBE-AD include the patient-reported global AD severity, numerical rating scale (NRS) worst or average itch in the past 7 days, the Skin Pain NRS, and the Sleep Quality NRS, which each take fewer than 30 seconds to complete. "You can have your nurses do this or can you have the patients fill out the form in the waiting area before they see you," Silverberg said.

He also advises asking patients about the number of nights they experience sleep disturbance and if they have difficulty falling asleep or have nighttime awakenings because of their AD. Symptoms of anxiety and depression can be assessed with the Hospital Anxiety and Depression Scale and the Patient-Health Questionnaire–9, which each take 2-3 minutes to complete.

Recommended assessment tools for other symptoms – such as bleeding, oozing, and xerosis – include the Patient-Oriented Eczema Measure, which takes 2-3 minutes to complete, and the Atopic Dermatitis Control Tool or the Recap of Atopic Eczema, which each take 2-3 minutes to complete.

Comorbid Health Disorders

Comorbid health disorders linked to AD are varied and include atopic comorbidities such as asthma or wheeze, hay fever or oculonasal symptoms, food allergy, recurrent infections such as herpes simplex virus, mental health disorders, alopecia areata, Th1-mediated comorbidities, and adverse events to medication such as venous thromboembolism, hypertension, and impaired renal or liver function. "All of these are important because if the patients have these at baseline, they may not be good candidates for some therapies that cause these types of side effects," Silverberg said.

Response to Therapy, Intensity of Lesions

As for response to therapy, clinicians can ask patients, "How do you feel you're improving?" But it's also important to assess the signs, symptoms, frequency of flares, and comorbidities as part of that response to therapy, "and of course the adverse events and treatment burden," he said.

For the intensity of lesions component of DESCRIBE-AD, Silverberg said that the Investigator's Global Assessment–AD is an effective tool for clinical use. "You can also use tools like the Eczema Area and Severity Index or the Scoring AD, but recognize these are challenging," and can be difficult to use if not well trained to use them, he said. "At the very least, do an Investigator's Global Assessment and do a body surface area measurement."

In his opinion, four key signs that should be assessed in clinical trials are erythema, edema/papulation, excoriation, and lichenification/prurigo nodules.

Burden of Disease

In terms of assessing AD disease burden, guidelines from the American Academy of Dermatology don't give a specific tool to use, but recommend asking open-ended questions, Silverberg said. "I would not recommend that, because when you ask an open-ended question, the flood gates open up because most patients are suffering miserably with this disease when it's uncontrolled.

"That's why it's valuable to use structured, validated tools like the Dermatology Life Quality Index and the Patient Reported Outcome Measurement Information System. They don't take a lot of time to complete, and you can look at the score and determine how burdensome their disease is, even in a busy clinical practice. They're not going to slow you down; they're going to speed you up and make you better at your therapeutic decision-making. I can guarantee you that most patients will love you for it. Sometimes patients say to me, 'you're the first doctor to ask these questions.' "

Extent of Disease

Finally, for the extent of disease component of DESCRIBE-AD, he emphasized the importance of doing a full-body exam to appreciate the affected body surface area, flexural versus extensor distribution, and involvement and severity of disease on special sites such as the face, hands, feet, genitals, and scalp.

Silverberg reported that he is a consultant to and/or an advisory board member for several pharmaceutical companies. He is also a speaker for Regeneron and Sanofi and has received a grant from Galderma.

This article originally appeared on, part of the Medscape Professional Network.


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