The Atopic Triad: Allergy, Asthma, and Atopic Dermatitis

As briefly mentioned above, the triad is composed of allergies, or more specifically allergic rhinitis, asthma, and atopic dermatitis. The reason that these three conditions are termed “the atopic triad” is because all three tend to occur together in an individual patient (Emfietzoglou, 2025). In other words, many patients suffer from all three. The typical progression of this triad cluster is that it begins as atopic dermatitis, more commonly known as eczema, and then develops into comorbid allergic rhinitis and finally asthma. This development is known as the “atopic march”. People with one or more of the conditions in the triad are at an increased risk of developing the other conditions and are typically highly sensitized to allergens and have an overactive inflammatory response (Emfietzoglou, 2025).

Each condition in the triad has its own causes, signs and symptoms, and treatments, but all share an overlapping chronic pathology of a highly sensitive inflammatory response (Emfietzoglou, 2025). Current data suggest that 31.8% of adults suffer from any one atopic condition and that anywhere from 2-6% of adults have all 3 coexisting conditions (Ng & Boersma, 2023; Pullerits et al., 2021).

As with any chronic condition, these diseases require frequent utilization of healthcare services, including specialty appointments for maintenance, acute care for flare-ups or complications, and prescription medications for both chronic and acute use.

According to the Centers for Disease Control and Prevention (CDC), there are around 1.8 million emergency department visits, and 183,000 hospitalizations related to asthma each year (Centers for Disease Control and Prevention [CDC], 2023b). Only around 1% of emergency department visits are for allergic reactions, however, there are more than 4 million outpatient visits for allergy symptoms annually (CDC, 2023a). Eczema accounts for nearly 2 million primary care and dermatology office visits annually (Singh & Silverberg, 2023).

The financial impact is also significant, both on an individual and systemic level. Recent data estimates that annual healthcare costs for people with eczema can range from $8,000 (for mild disease) to nearly $24,000 (for more severe disease) (Wang et al., 2022). Cost of asthma care is around $4,000 annually for individuals, and the individual cost of allergy management is around $300 annually (Asthma and Allergy Foundation of America [AAFA], 2025; Roland et al., 2021). The Asthma and Allergy Foundation of America estimates that more than $82 billion is spent annually in the United States on management of these conditions (AAFA, 2025).

There is also the consideration of vulnerable groups with increased risks of financial hardship when managing chronic disease. Not only does this lead to poorly managed atopic disease, but financial hardship further contributes to poverty and risk of severe disease, creating a vicious cycle that is difficult to escape. On a societal level, this just perpetuates the health disparities among the poor and vulnerable. Special care should be taken to identify vulnerable populations and understand the impacts of social determinants of health on atopic disease (AAFA, 2025). On a broad level, efforts to identify those at risk and ensure appropriate management of these conditions can reduce burden on the healthcare industry as a whole.

Eczema, often the first condition to develop of the atopic triad, is a complex condition with many causative and contributing factors, most often a combination of genetic and environmental factors (Cleveland Clinic, 2022).

There is a substantial genetic component to eczema, with family history being a common risk factor (Cleveland Clinic, 2022). The genes most often involved lead to dysfunctional skin barrier and hyperresponsiveness of the immune system.

In addition to genetic factors, environmental factors that contribute to the condition can include (Cleveland Clinic, 2022):

• Cold temperature
• Low humidity climates
• Calcium carbonate content in water (or “hard” water)
• Fragrances in soaps
• Fabric softeners
• Cosmetics
• Textured fabrics/clothing (such as wool, polyester, or other synthetic fabrics)
• Sensitization to certain proteins in foods (such as eggs, nuts, or dairy)
• Environmental allergens like dust mites
• Air pollutants common in urbanized areas 

There is also growing evidence to suggest that early life colonization and the makeup of a person’s normal skin and gut flora has an impact on the rates of atopic dermatitis (Nemeth et al., 2024).

Regardless of what particular triggers and risks an individual has, the condition typically begins with a disruption in the epidermal layer of the skin. The epidermis serves as the outermost layer of the skin, providing a protective barrier against pathogens, environmental toxins, and water loss. It also plays a key role in regulating hydration, producing keratin for structural integrity, and generating melanin to protect against ultraviolet (UV) radiation. 

Image 2:
Atopic Dermatitis

In addition to general dryness, the above factors lead to activation of the inflammatory response, with a barrage of mast cells, eosinophils, and T-cells responding to the area, causing inflammation and pruritus. When affected individuals scratch the area, this furthers the release of inflammatory markers and pruritogens, creating a vicious cycle. Keratinocytes also respond to the site of injury and eventually lead to lichenification of the skin (Nemeth et al., 2024). 

The resulting signs and symptoms of eczema include (Cleveland Clinic, 2022):

• Dry patches
• Itchiness
• Scaly, flaky, or crusty skin
• Thick leathery patches

On physical examination, patients with eczema will often have (Cleveland Clinic, 2022):

• Erythema
• Scaly or even crusted patches or plaques
• Excoriation 
• Vesicles
• Lichenification

Image 3:
Eczema

Eczema tends to appear in specific locations repetitively, based on age.

(Seattle Children’s, 2025; More, 2024)

Allergic rhinitis is also the result of a complex interaction between genetics and environmental factors. Pollens are among the most common causes of the condition, with hundreds of different trees, grasses, and weeds dispersing pollen into the air that then comes in contact with the upper respiratory tract of humans, causing sensitization (Cleveland Clinic, 2023). Mold spores, pet dander, dust mites, and cockroaches are also common culprits (Cleveland Clinic, 2023).

Image 4:
Allergic Rhinitis

• Nasal congestion or rhinorrhea
• Sneezing
• Red or watery eyes
• Itchy nose, throat, eyes
• Sinus pressure and headaches
• Increased mucus in the nasopharynx 
• Postnasal drip and subsequent sore throat
• Fatigue
• Coughing, wheezing, and difficulty breathing

On physical examination, patients with allergic rhinitis may have (Cleveland Clinic, 2023):

• Rhinorrhea
• Boggy, bluish-gray nasal turbinates (swollen) in the nose
• Nasal polyps
• Conjunctival injection (redness of the sclera of the eye)
• Middle ear effusion (fluid behind the eardrum)
• “Allergic shiners” (dark circles beneath eyes due to nasal congestion)
• “Allergic salute” (transverse nasal crease from frequent rubbing of the nose)
• Postnasal drip causing red, irritated throat

Image 5:
Allergic Shiners

Image 6:
Skin Allergy Testing

Finally, asthma, which often develops later for people who have already suffered from eczema and/or allergic rhinitis, is again an interplay between genetic and environmental factors. Over 25 different genes affecting inflammation or the immune system can play a role in asthma development. There is a strong genetic correlation, with twins both experiencing the disease 25% of the time (Sinyor & Concepcion Perez, 2023). Individuals who are genetically predisposed to asthma are more likely to develop the disease if they have exposure to environmental risk factors as well (Sinyor & Concepcion Perez, 2023).

Environmental factors that increase the prevalence of asthma include (Sinyor & Concepcion Perez, 2023):

• Frequent exposure to allergens (like pollen)
• Cigarette smoke
• Pollution
• Pesticides
• Metal or wood dust
• Paint fumes
• Glues
• Dyes
• Mold

There is a direct association between poor air quality (below U.S. Environmental Protection Agency or EPA standards) in industrialized areas and rates of asthma. Indoor air quality can also be impacted by gas stoves, pet dander, dust mites, and cockroaches (Sinyor & Concepcion Perez, 2023).

There is also a link between hygiene and bacterial colonization and development of asthma. Improved hygiene in modern society reduces the exposure to viruses and bacteria, which is actually shown to increase the rates of asthma (Sinyor & Concepcion Perez, 2023). The rate of asthma for children who live on farms, have frequent exposure to animals, and have more siblings is actually lower than that of children in smaller families with “cleaner” living conditions (Sinyor & Concepcion Perez, 2023). Birth by cesarean section and antibiotic use early in life both impacts development of the microbiome and have been shown to increase the risk of developing asthma (Sinyor & Concepcion Perez, 2023).

As a result, people with the genetic predisposition and sensitization to triggers have airway hyperresponsiveness. Various stimuli can cause an increased release of histamine from mast cells and increased free calcium that enhances smooth muscle contractility, both of which can occur in a much more hyperresponsive state than in people without asthma (Sinyor & Concepcion Perez, 2023).

There are two main phases of asthma exacerbation in the lungs. The early phase occurs when an individual encounters a trigger in their environment; IgE antibodies circulating in the body bind to mast cells and basophils which then release cytokines, histamine, prostaglandins, and leukotrienes when they come in contact with pollutants or triggers. Those cells contract the smooth muscles of the respiratory tree, causing airway narrowing.T lymphocytes produce interleukins to sustain inflammation and promote survival of eosinophils and basophils (Sinyor & Concepcion Perez, 2023).

This evolves into the late phase after a few hours, and the immune cells localize to the lungs, increasing bronchoconstriction and inflammation. There is also an influx of white blood cells (WBCs) and exudate and mucus in the respiratory tree, further blocking the airway. The combination causes significant airway obstruction and can increase work of breathing (Sinyor & Concepcion Perez, 2023).

Image 7:
Asthma

Over time, scarring and increased epithelial cells leads to a thickening of the basement membrane of the bronchial tree and irreversible airway remodeling (Sinyor & Concepcion Perez, 2023).

Symptoms of asthma commonly include (Cleveland Clinic, 2025):

• Coughing (often at night)
• Wheezing
• Shortness of breath
• Chest tightness

On physical examination, patients with asthma will often have (Cleveland Clinic, 2025; Sinyor & Concepcion Perez, 2023):

• Wheezing in one or more lung lobes
• Cough
• Drainage from nose (or postnasal)
• Edema of nasal turbinates
• Edema of throat 
• Barrel chest
• Signs of increased work-of-breathing including nasal flaring, grunting, tripod positioning, retractions, and/or accessory muscle use

The triggers as well as frequency and intensity of symptoms determine what classification of asthma a person has. For frequency, asthma can be classified as either intermittent or persistent(Cleveland Clinic, 2025):

1. Patients with intermittent asthma only have symptoms some of the time and can feel normal in between.
2. Patients with persistent asthma have symptoms most of the time and may not ever feel a complete resolution of symptoms, even when well-controlled.

Causes of asthma can be allergic, from environmental triggers like pollution and allergens, or non-allergic from factors like exercise, weather changes, stress, and illness (Cleveland Clinic, 2025).

The intensity level of asthma symptoms can be categorized as either mild, moderate, or severe based on how much the symptoms impact a person’s ability to breathe and how easily the symptoms are managed with medications (Cleveland Clinic, 2025).

Asthma is often differentiated from other respiratory illnesses through history and exam. Unlike a self-limiting viral infection, asthma symptoms recur over a period of time. Symptoms of asthma are also responsive to bronchodilators and can be reversed, whereas cough and wheezing from viral illness often does not respond to bronchodilators (Cleveland Clinic, 2025). A history of eczema and allergic rhinitis also strengthens the probability of an asthma diagnosis.

Additional testing like spirometry and chest x-ray may be used to support a diagnosis of asthma (Cleveland Clinic, 2025). Spirometry, the most commonly used test to diagnose asthma, measures three main metrics to determine the extent of airway obstruction and remodeling (Sinyor & Concepcion Perez, 2023):

1. Forced vital capacity (FVC), which is the total amount of air exhaled after a full breath
2. Forced expiratory volume (FEV1), which is the amount of air a person can forcibly exhale in 1 second
3. Peak expiratory flow rate (PEFR), which is the fastest rate a person can forcibly exhale air

With a spirometry test, a FEV1/FVC ratio of less than 0.7 confirms airflow obstruction that can be associated with conditions such as asthma or chronic pulmonary obstructive disorder (COPD) (Sinyor & Concepcion Perez, 2023). Obtaining a spirometry measurement before and then after the administration of a bronchodilator, would reveal an improvement in airflow or what is termed a “reversible change” or “bronchodilator responsiveness”, that is very suggestive of asthma (Sinyor & Concepcion Perez, 2023; American Lung Association, 2024).

While a chest x-ray is normal for up to 75% of asthma patients and cannot diagnose asthma by itself, it can help to provide valuable clues for a patient who is hospitalized with trouble breathing, during a severe attack, or can help eliminate other potential conditions that cause similar symptoms (Sorgen, 2025). It can also be most helpful as a diagnostic tool for children less than five years of age that are commonly unable to perform breathing tests or spirometry (Sorgen, 2025). Possible asthma signs and complications that can be detected via chest x-ray include atelectasis (collapsed alveoli), pneumomediastinum (air trapped between the lungs), mucous plugging, increased bronchovascular markings, bronchial wall thickening, and pulmonary hyperinflation (Sorgen, 2025; StatPearls, 2025; Bell, 2025).

For eczema, prevention looks like utilizing unscented soaps, fabric softeners, and hypoallergenic cosmetics, wearing nonabrasive clothing, and avoiding exposure to smoke, temperature extremes, pollutants, and allergens (food, environmental, or otherwise) as much as possible (Cleveland Clinic, 2022). In addition to avoiding triggers, patients are often advised to promote skin moisturization and repair the skin’s natural barriers. This is done through frequent moisturization of the skin with emollients like Vaseline ® or petroleum jelly, running humidifiers in the house, and keeping baths and showers short and with warm (not hot) water (Cleveland Clinic, 2022).

Persistent dryness and itching may need to be treated with topical corticosteroids to reduce inflammation and the overactive immune response. Topical steroids can be used for short bursts during flare-ups, usually twice daily. Common examples include (Nemeth et al., 2024):

• Hydrocortisone 2.5% (low potency)
• Triamcinolone acetonide 0.1% (medium potency)
• Betamethasone dipropionate ointment 0.05% (high potency)

There are also steroid free products like tacrolimus, pimecrolimus, and Eucrisa ® (crisaborole) that can be used to reduce side effects such as skin thinning or discoloration that can occur from frequent steroid use (Nemeth et al., 2024).

Because pruritus can be especially bothersome at nighttime, oral antihistamines can be used at night to reduce sleep disruption from itching (Nemeth et al., 2024). Diluted bleach baths once per week and intranasal mupirocin are also recommended for some patients to reduce the occurrence of secondary cutaneous infections (Nemeth et al., 2024). In severe cases, oral steroids and even immunosuppressant drugs may be indicated when trigger avoidance and more conservative treatment is not enough (Nemeth et al., 2024).

The prevention of allergic rhinitis also begins with avoidance of allergens. This can look like avoiding exposure to certain pets, high quality air purifiers and filters in the home, hard floors that are frequently swept, keeping windows closed, utilizing dust covers on bedding, getting rid of carpeting, frequently washing hands, and avoiding touching the face (Cleveland Clinic, 2023).

Whenever prevention is not enough, or exposure is unavoidable, antihistamines are the first line treatment. Antihistamines come in a variety of formulations, including oral pills and liquids, eye drops, nasal sprays, and inhalers. Common antihistamine choices include (Cleveland Clinic, 2023):

• Loratadine
• Cetirizine
• Fexofenadine
• Levocetirizine

These antihistamines work by blocking the histamine response and reduce nasal congestion, itchiness, and sneezing (Cleveland Clinic, 2023).

Short-term use of nasal decongestants like phenylephrine and pseudoephedrine can also be used to relieve sinus pressure and nasal congestion (Cleveland Clinic, 2023). Nasal and inhaled steroids like fluticasone can be used to reduce itchiness, congestion, and sinus pressure as well (Cleveland Clinic, 2023).

While the majority of the above treatment options are available over the counter, sometimes a prescription strength treatment is necessary. This can include leukotriene receptor blockers, which also play a role in the inflammatory response. Montelukast is a common choice for management of allergies when antihistamines are not enough. Oral tablets or subcutaneous injection for immunotherapy, or allergy shots, are also used in severe cases where symptom control has not been maintained with other measures (Cleveland Clinic, 2023).

For patients with asthma, avoiding triggers looks very similar to home maintenance measures used to minimize allergic rhinitis; frequent vacuuming and dusting to reduce dust mites, air purifiers and filters, getting rid of carpet in the home, keeping pets off of furniture, avoiding smoke, and keeping windows closed (Cleveland Clinic, 2025). Asthma can also be flared with exercise or with viral upper respiratory infections, so keeping an eye on symptoms and respiratory function is important (Cleveland Clinic, 2025).

Treatment of asthma is done via a stepwise approach. At a minimum, all patients with asthma will have an inhaled short-acting beta agonist (SABA), like albuterol, that can be used to relieve airway constriction, coughing, and shortness of breath, should those symptoms occur (National Heart, Lung, and Blood Institute, 2021). SABAs, or bronchodilators, work by selectively relaxing the smooth muscles surrounding the airways, relieving airway constriction and chest tightness. These can also be used preventively, such as before exercise, to keep airways open and reduce the occurrence of respiratory symptoms.

For patients with more persistent and frequent symptoms, a range of low, medium, and high dose inhaled corticosteroids (ICS) should be prescribed (National Heart, Lung, and Blood Institute, 2021). These medications include options such as (National Heart, Lung, and Blood Institute, 2021):

• Fluticasone
• Budesonide
• Mometasone

It is significant to note here that the Global Initiative for Asthma (GINA) recommendations are now emphasizing the importance of incorporating the use of early ICS-formoterol rather than SABAs as monotherapy (Dubin et al., 2024; Global Initiative for Asthma [GINA], 2024; Beasley et al., 2019). One main rationale is that SABAs are treating the symptoms, but not the disease (GINA, 2024). Reliever treatment with ICS-formoterol, such as budesonide-formoterol, has been associated with a substantial reduction in severe asthma exacerbations and emergency room visits as they help to reduce the inflammation in addition to creating bronchodilation (Watto & Williams, 2025; Krings et al., 2023; Beasley et al., 2019). In fact, according to Beasley et al. (2019), their published study on a year-long randomized controlled trial (RCT) including over 650 adult patients with mild asthma, budesonide-formoterol, being used as needed, was determined to be superior to albuterol alone, being used as needed, for the prevention of asthma exacerbations (Beasley et al., 2019).

Oral montelukast and inhaled long-acting beta agonists (LABAs) like salmeterol or formoterol, can also be added in until symptoms are well controlled and not interfering with sleep or daily function (National Heart, Lung, and Blood Institute, 2021).

Once well-controlled, patients with asthma may still experience flare-ups, either due to an increase in seasonal triggers, physical activity, or other illnesses (particularly viral upper respiratory illnesses). In the case of flare-ups with coughing and wheezing not managed by use of a SABA or when the patient is exceeding the recommended use of SABA inhalers (using it more and more often), a short burst of high dose oral corticosteroids is needed (National Heart, Lung, and Blood Institute, 2021). Recommended oral corticosteroids can include (National Heart, Lung, and Blood Institute, 2021):

• Prednisone
• Prednisolone
• Dexamethasone

Use of a peak flow meter at home to track patients’ baseline lung function as well as detect exacerbations is recommended (National Heart, Lung, and Blood Institute, 2021).

There are plenty of symptoms in all of the above conditions to impact quality of life for atopic individuals, but there are also a host of common complications and comorbid conditions that need to be considered.

With consideration for eczema, secondary infection of the skin is a common complication. Skin barrier dysfunction as well as breaks in the skin from rashes and scratching make overgrowth of bacterial, fungal, and viral pathogens all too easy. The most common organism responsible for a secondary skin infection in eczema is Staphylococcus aureus (S. aureus), which colonizes the skin of around 90% of people with eczema, compared to only 10% of the rest of the population.

Image 8:
Staphylococcus Aureus

Impetigo, boils, folliculitis, and cellulitis can all occur with an overgrowth of S. aureus. Intranasal mupirocin and diluted bleach baths can help reduce the density of S. aureus colonization on the skin and, therefore, reduce the risk of secondary bacterial infection. If an infection does occur, it can be treated with broad spectrum antibiotics ranging from topical, oral, and even intravenous, depending on infection severity. Antibiotic resistance due to improper and overuse of antibiotics sometimes complicates treatment of secondary bacterial infections (National Eczema Society, 2023; Nemeth et al., 2024). Therefore, antibiotics should be used judiciously in patients with eczema to reduce future treatment difficulties (National Eczema Society, 2023; Nemeth et al., 2024).

People with eczema are also more susceptible to herpes simplex virus (HSV) causing a secondary infection through compromised skin integrity (Nemeth et al., 2024). This condition is known as eczema herpeticum and causes widespread clusters of blisters as well as systemic symptoms like fever, fatigue, and malaise. Though this condition is very rare, it is a medical emergency and can lead to viral meningitis, encephalitis, and death (Nemeth et al., 2024).

Another secondary viral pathogen of concern with eczema is the coxsackie virus responsible for the common childhood illness, hand, foot, and mouth disease (HFMD). Eczema coxsackium presents with blisters over areas affected by eczema and additional symptoms like fever and diarrhea (Nemeth et al., 2024). Treatment of secondary viral skin infections is largely supportive in nature as well as maintaining hygiene of the existing lesions and the rest of the skin to prevent opportunistic bacterial infections.

Fungal pathogens such as candida and dermatophytes responsible for tinea may also cause secondary infection over eczema lesions, particularly on areas of the skin that are frequently dark or moist, such as between folds. Topical antifungals are often adequate to treat these secondary infections and there is not an issue of resistance as there is with bacteria (National Eczema Society, 2023).

Over time, chronic skin inflammation and scratching can lead to lichenification (thickened and leathery) and scarring.Long-term use of topical corticosteroids, especially at higher doses, can also atrophy the skin, causing a shiny, translucent appearance with loss of pigmentation and spider veins and more visible blood vessels beneath (National Eczema Society, 2023). Skin changes with the rash and with side effects from treatment can negatively impact self-esteem and potentially lead to anxiety or depression, especially in patients with more severe disease (National Eczema Society, 2023).

Allergic rhinitis that persists for more than 3 months at a time can develop into chronic rhinosinusitis, characterized by chronic inflammation of the paranasal sinus mucosa, causing nasal polyps to develop. While polyps themselves are typically benign, they can cause and contribute to a variety of symptoms like (Akhouri & House, 2023):

• Nasal congestion
• Loss of taste and smell
• Snoring
• Facial pain or pressure

Image 9:
Nasal Polyps

Hypertrophy of the adenoids and eustachian tube dysfunction are also common in patients with allergic rhinitis due to the chronic inflammation in the upper airway (Akhouri & House, 2023). These patients may report a feeling of ear fullness or pain, and frequent popping or pressure change sensations. This can further develop into otitis media with effusion and cough from postnasal drip (Akhouri & House, 2023).

Use of allergen desensitization treatment (or allergy shots) can lead to an increased risk of acute exacerbations or even anaphylaxis with the dosed exposure to allergens (Akhouri & House, 2023).

The chronic nature of asthma can cause a variety of acute and long-term complications, the most significant of which is airway remodeling. Permanent thickening of airways, increased mucus production, and loss of elasticity of the lungs reduces lung function and permanently impacts airflow (Hashmi & Cataletto, 2024). This contributes to (Hashmi & Cataletto, 2024):

• Coughing
• Wheezing
• Chest tightness
• Activity intolerance
• Increased hyperresponsiveness
• Exacerbations

Airway remodeling and use of corticosteroids also increases the risk of respiratory infections like cold viruses, influenza, and pneumonia. These types of infections are more likely to cause severe symptoms and asthma exacerbations in these patients.

Long-term use of inhaled corticosteroids can cause side effects like thrush and voice changes. Use of systemic corticosteroids can also have many side effects over time, including (Hashmi & Cataletto, 2024):

• Weight gain
• Osteoporosis
• Hypertension
• Diabetes
• Reduced immune function making patients more susceptible to infection

A prolonged asthma attack that does not respond to rescue treatment is known as status asthmaticus and is a medical emergency. This condition can lead to respiratory failure and death if not addressed emergently with intravenous corticosteroids, supplemental oxygen, nebulized bronchodilators, and mechanical ventilation if needed (Hashmi & Cataletto, 2024).

Image 10:
Asthma Attack

At any point in patient care and the diagnostic process, a detailed patient history is one of the most critical tools to identify risk factors, potential triggers, and patterns of disease overlap and progression. When gathering a history on patients with any indications for atopy, high suspicion for atopic disease should be present. Key historical components should include:

• Family History:
  • Patients should be assessed for first degree relatives with eczema, allergic rhinitis, food allergies, asthma, and other atopic and hyper-responsive immune conditions.
  • Patients with a strong family history should be considered high risk for developing atopy symptoms themselves and any symptoms should be evaluated with this in mind.
• Personal History (past medical and current illness):
  • Current or past diagnoses of any atopic conditions like eczema or allergies place a person at risk for developing future or comorbid atopic conditions.
  • History of severe reactions like anaphylaxis or hospitalization are also important for assessing disease severity.
  • Assess for any current flare-ups such as increased symptom severity, sleep disruption, pain, or signs of infection.
  • Assess for signs of compromised immune system like frequent infections.
  • Social determinants of health such as education level, socioeconomic status, neighborhood and home environment, access to healthcare services, etc all play an important role in determining a patient's risk of disease, severity, and ability to participate in disease management.
  • Assess barriers to utilizing the healthcare system such as affordability, transportation, language, etc. Does the patient have insurance and is it adequate to cover the costs of atopic disease?
• Triggers:
  • Ask about exposure to and management efforts for in-home triggers such as pet dander, carpeted rooms, cigarette smoke, dust mites, cockroaches, mold, and poor ventilation.
  • External environmental triggers like air pollution and chemicals or seasonal changes like pollen, temperature extremes, and humidity fluctuations may also be triggering and are much less in a patient’s control to manage.
  • Also ask about hygiene practices and cosmetic usage, looking for hard water, fragrances, harsh soaps or cleaning products, and bathing habits (frequency and water temperature) and skin response to these triggers.
• Medications & Treatment Adherence:
  • Reconcile medication list and look for prescription of and compliance with topical or systemic steroids, antihistamines, corticosteroid or bronchodilator inhalers, and immunotherapy.
  • Ask about side effects to any prescribed medications.
  • Assess compliance with non-prescription management techniques like skin care routines and use of moisturizer.

Understanding the ways that atopy affects multiple body systems is important and guides assessment. Even if a patient presents with a complaint of only one affected body system, the overlap in inflammatory response makes it prudent for nurses to assess other body systems to ensure simultaneous symptoms and atopic processes are not developing. Particular areas to pay attention to should include:

• Skin:
  • Assess skin color, texture, moisture, and uniformity.
  • Note any lesions or areas of impaired skin integrity, particularly in areas like the hands, wrists, elbows, and knees.
  • Note signs of secondary infection like crusting, pustules, weeping, and pain.
  • Note any skin thinning, pigment loss, hair loss, or other signs of side effects from long-term use of topical medications.
• Ear/Nose/Throat (ENT):
  • Assess the nasal mucosa for pale, blue, or boggy turbinates or nasal polyps.
  • Assess for postnasal drip, allergic shiners, and transverse nasal crease.
  • Assess for shotty cervical lymph nodes and otitis media with effusion.
  • Monitor for mouth breathing, watery eyes, and conjunctival injection.
• Respiratory:
  • Assess for cough, dyspnea, decreased oxygen saturation.
  • Listen to lungs, paying attention to any wheezing or decreased air exchange.
  • Assess for signs of respiratory distress, including retractions, nasal flaring, or tripod positioning.
  • Assess for signs of airway remodeling such as barrel chest and prolonged expiration.
• Systemic Assessment:
  • Assess for fatigue, sleep disruptions, difficulty concentration, or dizziness.
• Mental Health:
  • Assess for self-esteem impact, chronic absenteeism from work or school, social isolation, anxiety, or depression.

Patient education is a foundational principle for the nursing role and there is plenty of room for teaching when caring for patients with atopic conditions. The cornerstone of managing atopy is managing and avoiding triggers to prevent symptoms and flare-ups from occurring.

• Eczema Prevention Teaching:
  • Bathing practices should include use of lukewarm water limited to 5-10 minutes, avoiding harsh or heavily fragranced soaps, and adding water softeners where needed. Diluted bleach baths once per week are recommended for secondary infection prevention purposes.
  • A moisturizing routine of fragrance-free emollients twice daily is necessary even when skin is clear. Running a humidifier in living spaces during dry months is also useful.
  • Patients should avoid irritating, rough fabrics like wool, polyester, or other synthetic materials.
  • Dust frequently, vacuum often, cover bedding with hypoallergenic covers, and do not allow pets to sit on furniture or beds.
• Allergic Rhinitis Prevention Teaching:
  • Utilize a HEPA filter indoors. Keep windows closed. Clean frequently to remove and prevent dust, cockroaches, and mold.
  • Use nasal sprays or rinses to clear nasal passages.
  • Check pollen counts. Shower and change clothes after being outdoors during high pollen seasons.
• Asthma Prevention Teaching:
  • Educate on correct inhaler technique with a spacer.
  • Discourage cigarette smoking or exposure to second-hand smoke.
  • Encourage bronchodilator usage before exercise.
  • Encourage annual flu and covid vaccines, avoiding sick contacts, and wearing a mask when in crowded or public spaces.

The following image is of an inhaler spacer, as briefly mentioned above, that can be used to improve the use and effectiveness of inhalers by helping to deliver the medication more directly to the lungs versus it getting stuck in the mouth or throat (Roland, 2025).

Image 15:
Inhaler Spacer

In addition to trigger avoidance, education is also needed regarding maintenance therapy to reduce severity and avoid exacerbations. It is also important to teach patients about red flags and when to seek treatment for exacerbations.

• Eczema Management Patient Teaching:
  • Teach about appropriate usage of prescribed topical corticosteroids, usually used twice daily, or nonsteroidal topical medications.
  • Red flags include worsening itching, redness, pain, pustules, crusting, satellite lesions, or weeping lesions.
• Allergic Rhinitis Management Patient Teaching:
  • Counsel on use of daily antihistamines or leukotriene modifiers and/or nasal corticosteroids.
  • Discuss when allergen immunotherapy might be useful and refer when needed.
  • Red flags include itching and swelling of the respiratory tract, chest tightness, or difficulty breathing.
• Asthma Management Patient Teaching:
  • Teach about appropriate use of daily inhaled corticosteroid versus as-needed bronchodilators.
  • Assess for appropriate symptom control or when a patient may need to move up the stepwise approach of asthma management.
  • Teach the patient to utilize a peak flow meter periodically at home to monitor asthma symptoms and to detect potential exacerbations early on.
  • Utilize an asthma action plan to teach patients how to manage breakthrough symptoms and recognize when a flare-up is occurring.
  • Red flags include severe wheezing, difficulty breathing or speaking, no improvement with multiple uses of rescue inhaler, nasal flaring, retractions, cyanosis, and tripod position.

Nurses who work in urgent cares, emergency departments, and hospital settings are more likely to encounter patients who are experiencing a flare-up or severe disease. Patients may seek emergency care or require hospitalization for severe secondary skin infections, anaphylaxis, or other severe allergic reactions, and respiratory distress.

Nursing interventions common for patients experiencing atopic flare-ups can include:

• Administration of intravenous antibiotics or corticosteroids
• Assessment of wounds and changing dressings
• Administration of nebulized bronchodilators
• Monitoring respiratory status to detect worsening distress or signs of pending respiratory failure
• Administration of supplemental oxygen or monitoring of mechanical ventilation
• Administration of intramuscular epinephrine 

In the event that epinephrine is necessary, it is important to remember that the half-life of epinephrine is fairly short and the reaction to an allergen may outlast its effects. Therefore, patients who have had epinephrine administered for anaphylaxis need to be monitored for a return of symptoms and the need for subsequent epinephrine injection.

Additional monitoring that can be required in emergent situations is for the development of systemic infection or sepsis. Vital signs should be monitored for fever, tachycardia, and hypotension.

Collin is a 10-year-old male presenting to the pediatric clinic with complaints of frequent coughing with activity and disrupting sleep at nighttime for the past 3-4 weeks.

Collin has a history of eczema and allergic rhinitis related to seasonal pollen and cats. For his eczema, he uses a daily emollient and occasionally needs to use topical triamcinolone 0.1% BID for flare-ups. His allergic rhinitis is fairly well managed with air purifiers at home, keeping windows closed, and 10 mg cetirizine daily. The cetirizine also helps with his eczema itching at night. He does have an increase in nasal congestion when he lets the family cat sleep in his bed.

His mother has a history of eczema and asthma, and his older sister has a food allergy to peanuts.

Today, he reports around a month of a frequent dry cough and chest tightness when running in PE and after school soccer. It has gotten so bad that he has had to stop playing several times in the last week. This has increased to an intermittent dry cough even at rest, especially at night. His mother reports she let him use her albuterol inhaler on one occasion which seemed to help quickly.

On exam, he has clear eyes and ears, boggy nasal turbinates, and postnasal drip noted into the pharynx. His lungs have faint wheezing heard in the lower lobes as well as a diminished expiratory effort.

Collin is given a 5-day steroid burst of high dose prednisone to be taken daily and treat the current airway constriction. He is also given an albuterol inhaler for PRN use with cough, wheezing, and shortness of breath.

Collin returns in 2 weeks for a follow-up. His lungs are clear and he reports it is easier to breathe, but he is still experiencing nighttime coughing and significant coughing with activity, even with the albuterol prior to sports.

Because of this, he is started on a twice daily low dose fluticasone inhaler and given a diagnosis of mild, persistent asthma.

When he returns in a few more weeks, he reports that his symptoms are very well managed now, and he is no longer coughing at night or with activity. He did have a soccer practice last week where he forgot to use his albuterol beforehand and experienced some coughing, but this resolved quickly when he stopped playing to use the albuterol inhaler.

He is scheduled for follow-up in another 3 months to assess how he is doing with the season change.

Collin’s case is a classic demonstration of the progression of the atopic triad, with eczema preceding allergic rhinitis and asthma and a strong family history of atopic conditions. There is a high level of interconnectedness between the immune dysregulation of these conditions.

Management of the triad focuses on underlying inflammation and hypersensitive immune response, with slightly different and sometimes overlapping approaches for each affected body system.

Collin has an involved family who is used to making necessary home environment changes to minimize symptoms of atopy. Use of HEPA filters and keeping windows closed at home will help minimize his asthma symptoms as well as his allergy symptoms.

He is brought to the clinic in a timely manner to evaluate the new onset of cough and is started with treatment quickly. He is already utilizing an appropriate dosage of an antihistamine for eczema and allergic rhinitis which may help reduce his allergen and potential trigger exposure for his new diagnosis of asthma.

There is a gap in the time between when Collin is first assessed and given an oral steroid and when he is diagnosed with asthma and prescribed a daily inhaled corticosteroid. Given his family history of asthma as well as his existing presence of atopic conditions, his risk of asthma is relatively high, and he could have received more aggressive treatment or even referral for spirometry testing to better evaluate his lung capacity and the extent of obstruction.

It also seems that he could use more education on reducing exposure to triggers, like keeping the cat out of his room and using albuterol prior to activity.

At his age, the impact on his symptoms of his ability to participate in sports and peer activities may also affect his self-esteem or contribute to a comorbid mental health condition like anxiety or depression. Assessment of baseline mental health as well as monitoring intermittently for any emerging symptoms is important, especially in childhood when much of developmentally appropriate activity centers on interaction with peers and physical activity.

Collin’s case illustrates the complexity of managing the atopic triad, emphasizing the importance of a multidisciplinary approach. With proper interventions, education, and lifestyle modifications, his symptoms can be controlled, allowing him to lead a healthy and active life. Continued follow-up with healthcare providers will be essential to adjust treatment as needed and ensure optimal disease management.

Akilah is a 32-year-old woman with a history of the atopic triad (eczema, seasonal allergic rhinitis, and moderate persistent asthma). She presents to her primary care provider with a 2-week history of an eczema flare-up with increasing itchiness and pain.

Akilah’s symptoms are typically very well controlled. She adheres to a strict routine of moisturizing her skin, as well as taking 10 mg daily loratadine during spring months (currently not on it) and BID mometasone inhaler year-round. She reports recently moving to a different apartment and has had an increase in nasal congestion and sneezing. She has also needed her albuterol inhaler 3-4 times over the last week.

She noted that her hands were becoming drier and itchier than usual and developing a flare-up of irritated, scaly lesions. She has a prescription for 2.5% hydrocortisone for such symptoms but was unable to find it after moving. Her hands have worsened to painful, crusting, and oozing lesions over the last 4-5 days.

On exam, there are erythematous plaques with serous weeping and honey-colored crusting on the tops of her hands and onto her wrists with mild edema and tenderness. She also has some dry, scaly plaques on her antecubital and popliteal fossae.

Akilah is given a 10-day course of oral cephalexin 500 mg BID for a secondary bacterial infection, likely Staphylococcus aureus or Streptococcus pyogenes. She is also given a medium potency topical steroid, triamcinolone 0.1% for BID use to the dry patches. Skin care routines and triggers are reviewed. She is advised to restart her springtime loratadine for management of itching, especially at night.

When she returns 2 weeks later, the secondary infection has healed, and the erythema and scaling of the lesions has improved but not resolved. She also has a few new lesions on her neck and forearms that have come up since the previous visit. She is using the topical triamcinolone, which is keeping the lesions from becoming worse or infected, but is not resolving them.

Despite restarting the loratadine, she has persistent nasal congestion, though it is a little better. Her mometasone dosage is increased to combat persistent asthma symptoms.

After several more months of flare-ups and increased allergy and asthma symptoms, it is discovered that there is significant cockroach infestation and mold at the apartment Akilah had recently moved to. She is able to end her lease and move to a new location in a different part of town and her symptoms all begin to resolve very quickly, restoring her previous level of symptom control.

The prolonged exposure to indoor allergens in her new apartment perpetuated chronic inflammation, resulting in worsened skin barrier dysfunction, increased histamine response, and heightened immune system activation. The persistence of symptoms despite appropriate medical therapy suggests that the inflammatory response was being continuously triggered by the environmental exposures.

This case also highlights how housing conditions and environmental allergens play a major role in chronic disease management. Many patients, particularly those in urban areas or low-income housing, face barriers to managing allergen exposure due to factors such as mold, dust mites, cockroaches, and poor ventilation.

In Akilah’s case, ending her lease and relocating significantly improved her symptoms, demonstrating the powerful impact of environmental control in managing atopic disease. Healthcare providers should proactively screen for environmental and socioeconomic barriers and provide resources for allergy-proofing living spaces when possible.

Akilah typically has good management of the triad of conditions and normally has her symptoms under very good control. Prompt identification of a flare-up requiring medical attention helped her receive treatment in a timely manner. Her secondary skin infection was treated appropriately and resolved quickly without spreading. Overlapping treatment of her conditions allowed her to easily resume her antihistamine to manage nighttime skin pruritus.

Focusing solely on the secondary skin infection as a singular condition, and then later on the increasing asthma severity, rather than recognizing a simultaneous flare-up of all conditions in the triad limited the healthcare provider from recognizing that a systemic reaction was occurring and a more thorough history of triggers from being conducted. Earlier recognition of exposure to new triggers at a new housing location could have prevented this patient from experiencing prolonged exacerbation of symptoms. Inclusion of an assessment of living conditions should be a routine component of assessment of chronic conditions and patient history.

Akilah’s case highlights the importance of recognizing the interconnected nature of atopic conditions and the need for a holistic, patient-centered approach in managing chronic inflammatory diseases. Her history of the atopic triad indicates an underlying hypersensitivity to environmental allergens, which ultimately played a central role in her exacerbation. Her social history, primarily her housing conditions, needs to be considered as an important intertwined factor.