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ChenDermatologist
ChenDermatologist
Dr. Chen Yi-Jia · Dermatology Notes
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Patient education · AD / Comorbidities Per AAD 2022 + 2023 pediatric + UpToDate 2024 Content updated 2026-10-16 · Physician reviewed 2026-05-09

AD comorbidities & special populations
Atopic march, mental health, pregnancy, infections, infants

TL;DR:Atopic dermatitis is more than a skin disease — its comorbidities should be screened for actively. Daily moisturising from birth cuts incidence by about half, and introducing peanut and egg at the right age helps prevent food allergy; treatment choices differ in pregnancy, infancy and old age.

AD is the skin manifestation of systemic Th2 hyperactivity. AAD 2022 comorbidities guideline (Davis): seven essential screens — asthma (30-50%), allergic rhinitis (35-66%), food allergy (10-30% in children), eosinophilic esophagitis, depression/anxiety/suicidality, cardiovascular disease (adults), infections (S. aureus, eczema herpeticum, molluscum, tinea), ocular complications (keratoconus, atopic keratoconjunctivitis). Plus management of pregnant, pediatric (0-5y), elderly, refractory AD.

Cover and reading information
In this article
  1. The atopic march
  2. Seven essential comorbidity screens
  3. Pregnancy
  4. Infants and young children (0-5 years)
  5. Elderly
  6. Refractory AD
  7. Bottom line
Key Fact (Davis 2022, JAAD comorbid · Sidbury 2023, JAAD pediatric)

Infant AD → food allergy → asthma → allergic rhinitis is the well-known "atopic march". Routine infant moisturizer has not been shown to prevent food allergy (2022 Cochrane); timely early introduction of peanut and egg has better support (e.g. the LEAP trial).Adult atopic dermatitis significantly correlates with cardiovascular disease, depression, and suicidal ideation — not just "itchy skin", but systemic inflammation requiring long-term monitoring for comorbidities.

The atopic march

Infant AD → food allergy (1-3y) → asthma (3-7y) → allergic rhinitis (school age). Skin-barrier disruption allows allergen sensitization through the skin. Daily infant moisturizer probably does not prevent AD and may increase skin infections (large RCTs, 2022 Cochrane meta-analysis); evidence that early peanut introduction (4-11 months, with allergy assessment) prevents peanut allergy is clear (LEAP trial); the EAT trial of early introduction of multiple foods (including egg) was inconclusive (not significant in the intention-to-treat analysis).

Seven essential comorbidity screens

  • Asthma + allergic rhinitis (atopic triad — 30-66%)
  • Food allergy (10-30% in children) — diagnose by symptom-triggered history; do not screen all foods by IgE
  • Eosinophilic esophagitis — 2-4× risk; dysphagia, food impaction
  • Depression / anxiety / suicidality — OR 1.4-2.0; PHQ-2/GAD-2 yearly
  • Cardiovascular disease (adults) — moderate-severe AD MI/stroke ↑ 1.2-1.5×
  • Infections: S. aureus (80-90% colonization), eczema herpeticum (HSV — emergency, IV acyclovir), eczema coxsackium, molluscum, verruca, tinea
  • Ocular: atopic keratoconjunctivitis, keratoconus (from eye-rubbing), anterior subcapsular cataract; dupilumab-conjunctivitis 8-15%

Pregnancy

60% improve, 20% unchanged, 20% worsen. Safe: moisturizer, low-mid TCS (limited area), NB-UVB. Avoid: methotrexate, MMF, acitretin, JAK inhibitors. Limited data for biologics — mAbs theoretically transferred via placenta; certolizumab is the model "no Fc" example for psoriasis but no FDA-approved AD biologic has clear pregnancy positioning yet.

Infants and young children (0-5 years)

Daily moisturizer always; hydrocortisone 1% as first-line topical steroid; tacrolimus 0.03% ≥ 2 y; crisaborole 2% ≥ 3 months; dupilumab ≥ 6 months. Avoid super-potent steroids, oral JAKi (< 12 y; topical ruxolitinib is FDA-approved for mild-to-moderate AD ≥ 2 y), PUVA, chronic systemic steroids. Educate on early allergen introduction.

Elderly

Differential: seborrheic, stasis, drug eruption, CTCL, scabies, lymphoma. Avoid JAKi (≥ 65 y is black-box high-risk); prefer dupilumab/tralokinumab/lebrikizumab.

Refractory AD

Re-evaluate diagnosis (rule out CTCL, scabies, contact dermatitis, psoriasis overlap), biopsy if needed, address triggers (S. aureus, allergens, occupation), switch mechanism (dupilumab → upadacitinib; IL-13 → IL-31R), combine treatments, multidisciplinary referral.

Bottom line

AD is systemic Th2 inflammation. Annual screening for atopic march, comorbidities, mental health, infections, and ocular findings reduces respiratory, cardiovascular, and psychiatric morbidity. Each patient demographic — infants, pregnant, elderly, refractory — has tailored evidence-based care.