Reviewing Symptom Burden and Unmet Need in Patients With Atopic Dermatitis

Vivian Shi, MD, FAAD, associate professor of dermatology, University of Arkansas for Medical Sciences, reviews the symptoms of atopic dermatitis, the prevalence of the condition in her clinical practice, and the unmet needs of this patient population.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

Today we are joined by Dr Vivian Shi, dermatologist and associate professor of dermatology at the University of Arkansas for Medical Sciences. She offers insight into the prevalence and symptom burden of atopic dermatitis, as well as what unmet needs still exist for this patient population. Dr Shi?

Hello. My name is Vivian Shi. I am a med board certified dermatologist practicing in Little Rock, Arkansas. I'm currently an academic dermatologist and associate professor of dermatology at the University of Arkansas for Medical Sciences where I direct the clinical trials operation in my department.

I specialize in atopic dermatitis as well as other inflammatory conditions such as hidradenitis suppurativa.

Can you comment on the prevalence of atopic dermatitis in your practice?

When we look at classic atopic dermatitis, it's really these people with other comorbidities related to atopy. In my practice, because I'm an academic center, I specialize in atopic dermatitis. I, on average, see about 30 or so a week.

That's a really high-volume practice. Most of my patients are of color and that may be because I live in the south, and the UAMS Academic Center is the one and only tertiary referral center in the state. Most of my patients are moderate to severe in severity.

A lot of times that's their first stop, and a lot of times they could come also as a last stop when they have been through multiple other doctors unable to find relief for their condition.

What is the symptom burden for patients? How does this burden differ between mild and severe cases?

When I think of symptom burdens, as a clinician, what you see in the clinic room is they have rash, they have itch. Itch is probably the most common symptom that patients have, and many of them will have pain and skin discomfort related to the inflammation from atopic dermatitis, but that's just scratching the surface, pun intended.

What's beneath the surface that’s invisible but is significantly burdensome and impacts the quality of life for the patient and their family, as well as the socioeconomic burden, is that inadequately treated patients will have high rate of hospitalization. This is even in the era of biologics and systemic medications.

They'll have sleep disorders, mood disorders, like anxiety and depression, and overall well-being issues. Many of them will have behavioral issues, obesity, and weight challenges. Even underneath the surface of all that, those symptoms and socioeconomic burden, we're looking at really magnified health care costs.

People are unable to be productive at work and at school. There's absenteeism and presenteeism. They are more prone to getting into motor vehicle accidents and just day-to-day living accidents because of the lack of sleep, and mental health disturbance.

What we don't think about enough is, it goes beyond just a patient. Most of these patients are children, they often live with other people. The caregiver burden is often missed, and that comes with its whole entire baggage of socioeconomic burden and productivity loss as well.

What unmet needs still exists for this patient population?

There's a lot of unmet needs. You mentioned earlier how's it different between mild to severe disease. I would like for us to move away from the very strict definition of what's mild, what's moderate to severe, because if you look at the clinical trials, you have to hit certain exam criteria and statistics to fit the mold of moderate to severe, or mild.

In reality, it's how productive and happy patients are, and how much quality of life the patients can have. The unmet need now, I think, is we don't have a silver bullet. We have really good medications, but we don't have a good silver bullet where monotherapy is enough to get people to the finishing line and doesn't mean anything else.

The other unmet need is we don't have treat-to-target just yet, and we don't have good assays to look at the immune profile of the patient. That really prevents us from having a good prediction of who may be the candidate for medication A or medication B. Many of the patients will still need topical medications. We have traditionally limited options for topical medications.

When I say limited, it's not because we don't have a variety of them, we have a number of them available, none of them are really enough to get us to clear or almost clear. Topical corticosteroids traditionally carry the price tag of skin atrophy tachyphylaxis. We can't use it for a long-term in a lot of sensitive areas on the body, such as the face, the skinfolds, and whatnot.

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