Atopic dermatitis (AD) presents differently in adults than in children, reflecting the different immune pathways involved in the pathogenesis of AD. Jonathan I. Silverberg, MD, PhD, MPH, reviews ways in which these differences may influence diagnosis and treatment choices, as discussed during his session at the recent 2025 American Academy of Dermatology (AAD) Annual Meeting.

Following this presentation, featured expert Jonathan I. Silverberg, MD, PhD, MPH, was interviewed by Conference Reporter Medical Director Lauren Weinand, MD. Clinical perspectives from Dr Silverberg on these findings are presented here.

As I noted during my session at the 2025 AAD Annual Meeting, “Atopic Dermatitis in Adults: Not Just Big Kids,” the prevalence of AD is approximately 13% among US children and approximately 7% among US adults. For some individuals who are diagnosed with childhood-onset AD, the condition persists into adulthood. These patients may experience similar or varying disease manifestations over their life spans. Some patients have adult-onset disease with no history of childhood symptoms. Different genetic considerations may be implied in childhood- vs adult-onset AD, and studies show differences in which immune pathways are activated in children vs adults.

Patients with childhood-onset AD tend to have markedly higher rates of coexpression with severe asthma, hay fever, or food allergies. However, one study from the literature that included a cluster analysis showed that only 3% to 4% of patients follow a pure atopic march as originally described. So, while we know that atopic comorbidities occur with AD, particularly among children, it is important to remember that the sequencing is by no means rigid. In patients with adult-onset AD, a history of atopic comorbidities may be reported. However, these comorbidities are often of a milder nature, even when patients’ AD is severe. Again, this reflects the different immune mechanisms that are suspected of being involved.

There is discussion in the literature about the distribution of AD lesions based on age. For example, infants have more face, head, and neck involvement; toddlers have more extensor involvement; and older children and adults demonstrate more flexural involvement. In reality, however, there is not such a neat progression. While some adults with AD may have just as much head and neck dermatitis as affected children, the clinical picture can be quite different. Children with AD tend to have more acute and subacute lesions and more oozing and weeping lesions in general, particularly when they are affected by facial dermatitis during infancy. Children also have higher rates of follicular eczema and Dennie-Morgan folds.

In adults with AD, we see more dry, chronic eczema on the face, more prurigo nodules, and more signs of chronic disease such as lichenification or papular lichenoid lesions secondary to chronic rubbing of the skin. We see flexural involvement in all age groups, and this does not seem to be a significant differentiator between adults and children with AD. Hand and foot involvement, but particularly hand involvement, is more common in adults with AD. The prevalence of hand involvement starts to skyrocket during adolescence and peaks during young adulthood. It becomes a major challenge for many patients and requires a careful consideration of the differential diagnosis.

Studies have shown differences in the microbiome between children and adults. For instance, children tend to have more upregulation of Streptococcus and Haemophilus, whereas adults have more upregulation of Propionibacterium, Corynebacterium, and other anaerobes. We do not fully understand all the clinical correlates of these differences in skin microbiota, but they may account for different types of skin infections and varying vulnerability to bacterial toxins.

Currently, we have several topical treatments that are US Food and Drug Administration (FDA) approved for children and adults with AD. Most of these topical treatments are newer nonsteroidal therapies, including tapinarof, topical roflumilast, and topical calcineurin inhibitors. The efficacy and safety of these treatments seem to be comparable among children and adults.

When considering biologic therapies for AD, patient age is a significant factor. For example, dupilumab is FDA approved for use in patients aged 6 months and older. Others, however, are approved only for use in patients aged 12 years and older (eg, nemolizumab).

There have been several studies assessing the efficacy of dupilumab across different age groups. While some of these studies showed that the efficacy may be less in younger children compared with adults, the pediatric trials included more patients with severe AD compared with the adult trials. So, we are not sure if there are truly any age-related differences in the efficacy of this drug, but it is worth noting when considering differences in response to therapy based on age. Another benefit of dupilumab treatment is that it is FDA approved for moderate to severe asthma, and children and adults with moderate to severe AD may have comorbid asthma. For some patients, dupilumab could potentially treat not only the skin but also comorbid airway disease, allowing the prescriber to reduce polypharmacy and still accomplish their treatment goals.

As we know, children with AD can have failure to thrive, which impacts vertical growth. A post hoc analysis of children under 12 years of age with AD showed that dupilumab treatment led to catch-up growth and an increase in height compared with placebo. These are incredibly important data to include in our treatment-related discussions with patients and parents or caregivers. There is always going to be that general concern: How will this drug affect my child’s development? These data suggest that dupilumab treatment may help with physical development and may help affected children achieve catch-up growth. We have also seen, across studies in both children and adults, improvements in school performance, behavioral issues, and work productivity with dupilumab treatment.