Atopic march (AM) reflects the sequential appearance of allergic phenomena in predisposed individuals. It typically begins in the first months of life with the onset of atopic dermatitis (AD), followed by later development in childhood of IgE-mediated food allergy (IgE-FA), allergic asthma (AA), allergic rhinitis (AR), and eosinophilic esophagitis (EoE) (Fig. 1).1 In most cases, AD constitutes the first step. Therefore, several authors have focused on AD as a key therapeutic target for preventing the AM.

Fig. 1.

Atopic march. Atopic dermatitis (AD) typically develops first, followed by IgE-mediated food allergy (IgE-FA), allergic asthma (AA), allergic rhinitis (AR), and eosinophilic esophagitis (EoE). Source: authors’ own elaboration. AD: atopic dermatitis; IgE-FA: IgE-mediated food allergy; AA: allergic asthma; AR: allergic rhinitis; EoE: eosinophilic esophagitis.

In this article, we describe the results of a national multicenter survey conducted among dermatology residents and attending dermatologists in June 2023 on their knowledge and opinions about the AM. We also present a brief review of the literature centered on recent developments related to this entity.

Table 1 illustrates the survey results. A total of 178 participants completed the survey, of whom 159 (89.3%) were attending dermatologists, with the largest proportion being dermatologists with >25 years of clinical practice (37.1%). The autonomous communities with the highest participation were Madrid (n=39; 23%), followed by Andalusia (n=27; 16.6%), and Catalonia (n=24; 14.7%). Most respondents supported the existence of the AM (n=148; 83.2%) vs 12.9% who had doubts and 2.3% who did not believe in its existence. In addition, nearly 90% agreed that AD is frequently the first sign of the AM. When asked about contributing factors in the AM, the most frequently cited were genetic factors (n=166; 93.3%), followed by environmental (n=163; 91.6%) and immunologic factors (n=150; 84.3%). More than half of respondents (56.2%; n=100) supported the use of preventive measures in young children with AD to reduce the risk of developing additional components of the AM. The most widely endorsed preventive measures were emollients (64%), avoidance of tobacco exposure (53.4%), and topical corticosteroids (43.8%). On the other hand, in infants without AD but at risk of developing it, 53.9% (n=96) supported the use of preventive measures. In this scenario, the most frequently endorsed interventions were emollients with lipid combinations (73%), avoidance of tobacco and environmental pollution (68.1%), and breastfeeding (67.5%). Approximately two-thirds of respondents believed that greater AD severity increases both the likelihood and severity of AM signs. Finally, nearly all respondents (n=157; 96.3%) agreed that dermatologists should play a central role in the management of AD and, when necessary, be responsible for referral to other specialists (allergists, pulmonologists, etc.). Since AD precedes other AM components, preventing AD—and, when present, initiating early treatment—may serve as a strategy to prevent the AM. Table 2 illustrates the main studies proposing methods to reduce AD or the AM.2–5

Therefore, according to the results of our survey, the main measures to limit AD and the AM would be emollients, breastfeeding, and avoidance of tobacco smoke. Evidence regarding emollients for preventing the AM is contradictory.2,3 In contrast, several studies support breastfeeding and tobacco avoidance for AM prevention.3,4 Regarding other potential preventive strategies, there is uncertainty on the utility of probiotics and prebiotics, early pet exposure, immunotherapy, or topical calcineurin inhibitors.6 These variable findings mirror our survey results, in which only 20–40% of respondents indicated they would use probiotics, prebiotics, topical or oral corticosteroids, or biologic therapies targeting IL-4 or IL-4/13 to prevent the AM.

We are currently in a period of rapid expansion in knowledge related to the pathophysiology of AD and the AM. This knowledge has led to the development of new therapeutic targets (Supplementary Table 1).8 The next major challenge is the ability to determine each patient's specific genotype and, consequently, to select individualized therapies.7 It is anticipated that such targeted treatment will reduce AD and the associated processes of the AM.

In conclusion, most Spanish dermatologists believe in the existence of the AM and support the need for early preventive interventions. The main preventive measures identified were “plus” emollients, breastfeeding, and avoidance of tobacco exposure.