Atopic Dermatitis Is a Global Health Disease, Not Just a Skin Disease
Host Buchi Neita, PA-C, and co-host/producer Jennifer Conner, PA-C, open the conversation with guest Dr. Lisa Swanson by reframing how clinicians should think about pediatric atopic dermatitis. As Swanson puts it, everything is happening in these kids. Beyond the itch and disrupted sleep clinicians already recognize, she points to the atopic march plus a longer list of associations she sees in her AD population: ADHD, anxiety, depression, learning disabilities, and autism spectrum disorder.
Swanson also flags decreased bone health, including osteoporosis, osteopenia, and an escalated chance of fractures. Her point to APPs is that while we treat what we see on the skin, much more is happening below the surface. She spends real clinic time correcting the misinformation that a child just needs to stop scratching, because that framing minimizes a systemic process that deserves systemic thinking.
Sleep, Behavior, and the Whole Family Under Strain
Swanson explains that itch peaks at bedtime, and it is not simply because daytime distractions fall away. There is a circadian rhythm to some itch cytokines, so it is physiologic for itch to ramp up right when a child should be settling down. The result is scratch-scratch-scratching that parents hear from another room, poor sleep, and trouble focusing the next day at school or at home.
The burden extends across the family. Swanson cites data that parents of kids with AD lose roughly an hour to an hour and a half of sleep each night, and she relays a striking claim she heard from a speaker but could not verify in print: that AD was the number one medical reason for parental divorce. She finds it plausible given sleep deprivation, watching a child struggle, differing opinions on management, and even parental guilt over the inherited tendency. Neita reinforces this with a case in which mom and dad disagreed visit-to-visit about starting a biologic, until sharing the data brought them to agreement.
On behavior, Swanson is candid that the field does not fully know whether these children truly have ADHD or whether itch and sleep deprivation manifest in a way that meets diagnostic criteria. What she has observed: when patients with AD and ADHD start dupilumab for their skin, their ADHD medication use decreases, suggesting the eczema may be driving much of the picture.
Elimination Diets and Steroid Phobia: Two Traps to Navigate
Swanson warns that elimination diets can be dangerous and are rarely helpful for the eczema itself. She emphasizes that the science points the other way: the broken skin barrier lets aerosolized food particles trigger an abnormal immunologic response that becomes allergy, so good treatment of AD lowers allergy risk. Neita and Swanson both cite the memorable line from Dr. Peter Leo: through the skin, allergies begin; through the diet, allergies stay quiet.
She names two exceptions. First, the child whose eczema worsens within 30 minutes of eating a food, which she learned is food-exacerbated eczema, pathogenetically distinct from IgE-mediated allergy; an allergist advised her that continued small periodic exposure is preferable to complete avoidance, since strict elimination can raise the chance of true IgE food allergy. Second, the infant under age one with significant AD and bloody diarrhea, suggesting dairy protein sensitivity, should be followed by pediatric GI and avoid dairy, with most children outgrowing it.
On corticosteroids, Neita notes lifetime steroid exposure and reports of osteopenia with long-term use. Swanson observes the cultural pendulum has swung so far that overuse is now uncommon; parents react to the word steroid as if it were a swear word. She is grateful steroid phobia peaked in an era when non-steroid topicals and systemic therapies exist, rather than 15 years ago when clinicians had nothing else.
The Growth Data and How to Use It in the Room
Swanson explains the mechanism she finds most compelling: growth hormone peaks during sleep in children, so disrupted sleep from itch blunts growth hormone, which also contributes to bone strength and helps explain the bone findings. Children with AD tend to track small on growth curves, and effective control changes that trajectory.
She cites a dupilumab study in six-to-eleven-year-olds: over 16 weeks, about a third of children on dupilumab grew at least five percentiles, versus roughly 10 percent on placebo, along with increased bone growth biomarkers. She notes six to eleven appears to be the sweet spot compared with younger and older groups, and that because dupilumab is currently the only agent approved under 12, it is the only drug with this data. She is hopeful other agents will study growth as they reach younger indications.
Practically, Swanson says talking about growth moves the needle better than any other comorbidity. Parents may tune out EOE and asthma, but the possibility that eczema is making their child short gets immediate attention, especially given the limited window for growth. Her conversation opener: ask the child's age and how they are tracking on growth curves, frame short stature as one of eczema's trickle-down effects, connect it to sleep, and express empathy that when the child is not sleeping, neither is the parent. Her tagline: ready, set, grow.