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Background Atopic dermatitis (AD) is a common, chronic, relapsing, inflammatory skin disease causing a variety of dermatologic signs and symptoms, affecting patientrs quality of life. While treatment options are available, they are of variable effectiveness. This study sought to characterize patient-reported AD signs and symptoms, flare, and associated bother, by disease severity and control. Methods Adults diagnosed with AD were recruited through the National Eczema Association (NEA) and clinical sites and completed a web-based survey including the Patient-Oriented SCORing Atopic Dermatitis (PO-SCORAD), Recap of Atopic Eczema (RECAP), and Skin Pain numeric rating scale (NRS), as well as questions on previous/current clinical presentation, flare frequency and severity, past/ present AD treatment, and sociodemographic characteristics. Results A total of 186 participants completed the survey (mean age 39.7 years, 80% female). The most frequently reported current AD signs and symptoms included dryness, itch, redness, roughness, and flaking skin, and the most bothersome were itch, dryness, and redness (63%). The majority of participants (84%) were either currently experiencing a flare or had experienced one within the past month. The most common signs and symptoms that grew worse during the most recent flare were itch and redness across all disease severity groups. Participants most often experienced one to three flares in the last three months. Flare frequency, duration, and average severity increased with greater disease severity and lack of disease control. Conclusions The results of this study demonstrate the diverse and considerable symptomatic burden experienced by people with AD, even while being treated for AD. J Drugs Dermatol. 2021;20(11):1222-1230. doi:10.36849/JDD.6329.

A scale is defined as a flaking of the skin owing to increased loss from the stratum corneum. This may be caused by the production of abnormal keratin or keratin that is produced at an increased rate, as occurs, for example, in psoriasis. Damage to the stratum corneum also leads to scaling, and scaling may be associated with eczema and infections. In keratoderma, the horny keratin layer of the skin is formed normally but is not shed at the normal rate. As a consequence, there is a build-up of a thickened keratin layer of the skin that does not scale, but may create a similar effect of dry flaking skin. This problem may result from an underlying congenital abnormality affecting the skin or as the result of persistent pressure and trauma (du Vivier, 2002: 11).

The severity of scaling disorders can be evaluated objectively using the D-Squame technique coupled with image analysis. The parameters of scaling derived using this approach need to be clinically relevant and should have greater discrimination than visual grading. Improvements to an existing method that fulfil these requirements are presented. Three scaling parameters were calculated using image analysis of digitized video-captured images of obliquely lit D-Squame samples. These parameters were compared to clinical scores of scaling made by five observers from photographs of the same areas sampled with D-Squame. In addition, two clinical studies were carried out to assess moisturizer effects on different degrees of xerosis, and to compare two different moisturizer preparations. The three scaling parameters gave correlation coefficients, r, between 0.6 and 0.75 when compared with global clinical scores of scaling. Significant reductions in all parameters were observed with 2 weeks of moisturizer use on lower leg skin with marked xerosis compared to an untreated control. The same moisturizer had a similar effect on milder xerosis of the forearm, and showed a greater decrease than a moisturizer with lower glycerol content. Increases in skin hydration, as measured with a corneometer, were also seen in both clinical studies, and corresponded well with D-Squame results. Differences in the degrees of scaling between these two anatomical sites were also detected with this technique. In a previous publication, the same technique was shown to be repeatable and reproducible; in the current article its correlation with clinical observations of scaling or flaking skin has been demonstrated.