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  • decodeMR Team

From Rash to Remedy: Advancing Atopic Dermatitis Management – Q & A session with an Expert.

(Focus - Singapore)


Atopic Dermatitis (AD) can have a profound impact on individuals' quality of life, causing persistent itching, discomfort, and visible skin changes. The burden of AD goes beyond physical symptoms, as it can lead to emotional distress, sleep disturbances, and even social isolation. Understanding and effectively managing AD is crucial not only for the affected individuals but also for their families and communities.

To delve deeper into this subject, we had a discussion with Dr. Kok Wai Leong, a renowned Dermatologist from Singapore. Through our conversation, Dr. Kok sheds light on the unique challenges of managing AD within Singapore's environment. Moreover, he unveiled the transformative role of AI and machine learning in diagnostics and personalized treatment approaches that will equip you with the tools to attain improved outcomes in your AD management journey.


Dr. Kok Wai Leong is a Dermatologist and Consultant currently serving at Mount Elizabeth Hospital, Singapore.




In atopic dermatitis, there is a vicious cycle of itching and scratching. In order to alleviate the symptoms, we have to break this cycle. There are different methods we can employ, whether it is through medications or methods like behavioral changes.

Atopic Dermatitis (AD) usually begins in childhood. However, the presentation may be delayed and initially manifest as mild itching. What signs or symptoms should parents look out for in their child that could indicate Atopic Dermatitis?

Dr. Wai Leong - AD is characterized by scaly red rashes usually located on the skin fold areas, like the neck and the bends of your arms and legs. These are usually very itchy; when the child scratches, it may ooze or bleed.

So, at what point should they seek help from a dermatologist?

Dr. Wai Leong - I think it's important to seek help early from a dermatologist to establish the diagnosis and then develop a plan for the child. I believe that early diagnosis will contribute to better control of the condition.

What are the special precautions to be taken to alleviate symptoms and prevent AD complications in children?

Dr. Wai Leong - In atopic dermatitis, there is a vicious cycle of itching and scratching. In order to alleviate the symptoms, we have to break this cycle. There are different methods we can employ, whether it is through medications or methods like behavioral changes. One important factor for every patient is identifying what triggers their atopic dermatitis.

The Atopic Dermatitis Quality of Care Initiative (ADQoC) found that patients with AD were often misdiagnosed, or the severity of their disease was mis-assessed.[1] What are the main differentiating factors or symptoms that you look to accurately diagnose and assess the severity of AD in your patients?

Dr. Wai Leong - The key is to obtain a detailed medical history and then a thorough physical examination to exclude other causes of the rash. Atopic dermatitis is a clinical diagnosis. Dermatologists utilize a set of internationally adopted criteria for atopic dermatitis to make an accurate diagnosis. There are also objective scales that we employ to assess the disease severity.

In the local context, there are alternative therapies that patients may explore, and some of these treatment options claim to address the root cause or even provide a cure for atopic dermatitis.

Is Atopic Dermatitis often misdiagnosed in Singapore?

Dr. Wai Leong - In Singapore, there is good access to specialist care. However, there are instances where the clinical presentation is not typical and may be difficult to differentiate. In such instances, a referral to a dermatologist is suggested.

Are there any other challenges you observe in treating and managing Atopic Dermatitis in Singapore?

Dr. Wai Leong - In the local context, there are alternative therapies that patients may explore, and some of these treatment options claim to address the root cause or even provide a cure for atopic dermatitis. So patients or families may look at such alternative therapies as the primary treatment. There may be a lack of understanding of the different treatment options available to patients. These may be barriers for patients to seek help for their atopic dermatitis.

Doctor, you mentioned these alternative treatment options, right? Can you give me some examples of that?

Dr. Wai Leong - These include therapies like traditional Chinese medicine, and for the Indian community, ayurvedic medicine, as well as bioresonance therapies.

Atopic dermatitis co-exists with food allergies, allergic rhinitis, and asthma for the younger population. In the adult population, sometimes it can be associated with a higher risk of cardiovascular complications and psychiatric conditions.

What about steroid phobia, doctor? Is it a challenge?

Dr. Wai Leong - Yes, definitely. Steroid phobia is common here, especially for children, because of the perceived effects on the immune system. Parents are also worried about thinning of the skin with prolonged usage. But I find that one factor that promotes steroid phobia may be a negative influence portrayed by the media or social media. These are easily propagated in social media nowadays, which gives a lot of fear about using topical steroids. We must strive to educate our patients on the proper use of their topical creams, including topical steroids.

Studies suggest that over 25% of people with atopic dermatitis develop asthma. The risk of asthma is even higher with increasing disease severity. [2] What underlying mechanisms contribute to the association between atopic dermatitis and asthma?

Dr. Wai Leong - Both conditions share common immunological activation pathways, and there is a well-described phenomenon called the atopic march. It starts with atopic dermatitis early in infancy or childhood, leading to a disrupted skin barrier, skin microbiome dysbiosis that allows for sensitization to allergens, and the development of asthma. We know that some treatment options overlap or are similar in patients with asthma and atopic dermatitis.

Are there any other comorbidities/conditions you usually observe in AD patients in your practice?

Dr. Wai Leong - Yes, atopic dermatitis co-exists with food allergies, allergic rhinitis, and asthma for the younger population. In the adult population, sometimes it can be associated with a higher risk of cardiovascular complications and psychiatric conditions.

Could you brief us on your treatment plan in such situations?

Dr. Wai Leong - The key is having a holistic management plan, not just treating the skin. So in instances where there are concurrent comorbidities, we need a multidisciplinary approach. Specifically for the skin, I think it is important to address the impaired skin barrier, restore the skin microbiome, and then use the different treatment options to control skin inflammation.


Different types of machine learning modalities are in the pipeline, including more sophisticated deep learning algorithms that have also been reported to be useful. One limitation is the lack of a large and diverse image database that accounts for differences in the skin of color and adjusts for nuances in the skin phototypes.

Recently, I read an article stating that a dermatologist team has developed an artificial intelligence (AI) model that empowers atopic dermatitis (AD) patients to detect complications from bacterial or viral infections and distinguish between eczema and skin lesions caused by a type of blood cancer. [3], [4] In this context, could you comment on the role of AI in improving the diagnosis and treatment outcome of dermatological disorders like AD?

Dr. Wai Leong - I have an interest in medical technology, and I have been keeping my eye on the development of artificial intelligence. AI in dermatology began with skin cancer and melanoma detection, but this has been expanded to other inflammatory conditions like atopic dermatitis. In this context, the common form of AI used is neural networks. This approach allows us to utilize AI to find patterns that are not easily discernible to a human. It is useful as a triage tool and to detect early complications so patients can quickly seek help. AI can also be important in areas where access to dermatologists or dermatological care is difficult.

Are there any other AI-based interventions in the pipeline that help in the diagnosis of AD?

Dr. Wai Leong - Different types of machine learning modalities are in the pipeline, including more sophisticated deep learning algorithms that have also been reported to be useful. One limitation is the lack of a large and diverse image database that accounts for differences in the skin of color and adjusts for nuances in the skin phototypes. However, I believe that these barriers can be overcome in the future, which will improve the uptake and utilization in dermatology.

What other interesting trend do you foresee in the treatment and management of Atopic Dermatitis in the near future?

Dr. Wai Leong - Currently, we are in a very exciting era of precision medicine. In the future, we can look at treatment options being more personalized to the individual, considering the different genetic makeup plus the individual characteristics of the person with AD. I think precision medicine will be the future for the management of AD.

To conclude our session, what is your key takeaway message to Atopic Dermatitis patients for effective management of their condition?

Dr. Wai Leong - I want to emphasize that atopic dermatitis is treatable; new and very efficacious treatment options are available, especially in the last two decades. Therefore, do not think that there's no good treatment available for AD; on the contrary, it is important to treat your AD well to prevent complications.


Thank you so much Doctor!


References:

  1. https://onlinelibrary.wiley.com/doi/10.1111/dth.15259

  2. Bieber T. Atopic dermatitis. Ann Dermatol. 2010 May;22(2):125-37. doi: 10.5021/ad.2010.22.2.125.

  3. Paller AS, Spergel JM, Mina-Osorio P, Irvine AD. The atopic march and atopic multimorbidity: Many trajectories, many pathways. J Allergy Clin Immunol. 2019 Jan;143(1):46-55. doi: 10.1016/j.jaci.2018.11.006.

  4. Hogarty DT, Su JC, Phan K, Attia M, Hossny M, Nahavandi S, Lenane P, Moloney FJ, Yazdabadi A. Artificial Intelligence in Dermatology-Where We Are and the Way to the Future: A Review. Am J Clin Dermatol. 2020 Feb;21(1):41-47. doi: 10.1007/s40257-019-00462-6.



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