Confronting Issues and Challenges Beneath the Surface: Current AD Management Strategies
Managing Mild to Moderate Disease With Aaron Drucker, MD, SCM, FRCPC
Regardless of disease severity, basic skin care is incredibly important for the management of atopic dermatitis (AD). We know that disruption of the skin barrier is critical in the pathogenesis of AD. It can be the primary cause of an AD flare, but it can also happen secondary to inflammation, and the disruption manifests in the measurement of transepidermal water loss (TEWL). As dermatologists, we want to encourage regular moisturization immediately after bathing to help reduce barrier disruption and decrease inflammation.
For people who have truly mild AD, they might be able to get away with just using moisturizers. However, most patients have at least a moderate degree of inflammation in the skin along with itching and redness, which indicates the patient probably needs more than just a moisturizer. Prescription topical medications, such as corticosteroids (TCS), calcineurin inhibitors (pimecrolimus and tacrolimus; TCI), and phosphodiesterase (PDE) 4 inhibitors (crisaborole) all work by reducing inflammation in the skin.
TCS have been available for an incredibly long time. Patients are often hesitant to use steroids because they are concerned about side effects, but we know that for the vast majority of patients, TCSs are safe without any side effects, especially when used appropriately. Dermatologists should stress using TCS as prescribed by the physician. We usually use milder TCS for the face and any fold areas, whereas more medium-potency TCS can be applied to other areas of the body. Sometimes we may need to escalate a patient to more significantly potent TCS for areas such as the hands and feet or any areas of thick AD.
Nonsteroid medications—pimecrolimus, tacrolimus, crisaborole—can be used anywhere on the body. I most commonly prescribe them in those more sensitive areas, including the face and folds. A good example of application would be for AD around the eyes, where we want to avoid potential eye side effects of TCS, such as increasing the risk of cataracts and glaucoma.
While I am confident that TCS are safe, it is good to have these TCI and PDE-4 alternatives, particularly for patients who are not doing well with TCS or they have AD in areas that are potentially more sensitive to TCS side effects.
Managing Mild to Moderate Disease With Zelma Chiesa Fuxench, MD, MSCE
A great topic that our patients ask us about regarding skin care practices is bathing. We see bathing practices all over the place, from patients who bathe maybe once a week to those who do it every day. Bathing can have different effects on the skin depending on how it is carried out. For example, we do know that if you bathe with water, you can hydrate the skin while removing scale, crusting, and allergens that may be in contact with the skin. We also know that when water evaporates from the skin, we can have increased TEWL, which can result in worsening of skin dryness.
When we look at the evidence to determine the best bathing practices, we see that there are very little objective data. While there is no clear guidance on the optimal bathing frequency or duration for patients with AD, patients with AD may shower or bathe once per day, especially if they have signs of crusting on the skin, and moisturizer application follows the bath which is a critical step to prevent worsening of skin dryness.
A related topic is the soak-and-smear approach. Again, there are not a lot of objective data to support its use. However, from personal experience and that of my colleagues, we have seen that in some cases with widespread and significantly inflamed skin, there can be benefit to soaking in plain water followed by immediate application of a prescribed anti-inflammatory medication, such as TCS, without drying the skin off.
Typically, when I counsel patients on this, I recommend trying to use a non-soap-based cleanser. This would be a cleanser with a more neutral to lower pH similar to that of the skin. It is also important to look for keywords such as hypoallergenic or fragrance-free as well as the National Eczema Association (NEA) Seal of Acceptance, which can make it easier to recognize products that may be more appropriate for AD skin.
Once past basic skin care, how do we select appropriate topical prescription treatment options for our patients with AD? Nowadays, we have three different options to choose from: TCS, TCI, and PDE-4 inhibitors. The decision of which topical agent to use does depend on many different factors. For example, the age of the patient can be important; in the case of TCI, tacrolimus 0.03% is approved for children ages 2-15 and adults, but tacrolimus 0.1% is only currently approved for adults. We also need to consider the anticipated duration of treatment. Is the prescription topical being used for an acute flare, or is it for maintenance therapy? We might decide to use a higher-potency TCS for a shorter period to treat an acute flare vs a mid- to lower-potency TCS, a TCI, or a PDE-4 inhibitor for long-term use. Further, patient preference of the vehicle—ointment, cream, gel, lotion, solution, shampoo—can affect our prescribed topical therapy. It is important that this be also discussd with the patient as patient preference can impact adherence to treatment. For example, if my patient does not like to use ointments and I prescribe an ointment, that patient is probably not going to use their prescription appropriately or even at all.
An often-overlooked factor is also the number of applications. Most of these topical medications are prescribed for twice-daily use. However, in some cases, once-daily use is also perfectly acceptable. What abou the risk of systemic absorption? This is an important thing to consider particularly in children, who tend to have proportionately greater body surface area-to-weight ratio and, as a result, a higher degree of absorption for the same amount applied. It is important to recognize that all of these factors can influence which topical therapy we prescribe for our patients with mild-moderate disease.
Managing Moderate to Severe Disease With Dr Drucker
Regardless of how severe a patient’s eczema is, moisturizing regularly and use of topical anti-inflammatory therapy are both still cornerstones of treatment. Even people who have severe AD sometimes improve dramatically with just those measures. But there are many patients for whom topical therapy is not enough. The conversation turns to things such as phototherapy, which is UV light therapy, and systemic therapy, including different pills or injectable medications that work in some way by modulating the immune system to try to get at the inflammation of AD and decrease that inflammation systemically.
Right now, the systemic therapies that we have available are cyclosporin and methotrexate, which are the two best-studied older medications for AD. Azathioprine and mycophenolate are two other immunosuppressive medications that we sometimes use. Dupilumab was the first biologic therapy approved.
We are lucky now that we have several new medications that seem to be coming in the near future. Some of them are injectable biologics, like dupilumab, and others are oral medications called Janus kinase (JAK) inhibitors. While right now the choice is between the older conventional agents and dupilumab, soon there will be all sorts of other medications added to that decision-making process.
The choice of whether to move to some therapy beyond topical treatment is complicated and patient-dependent. There are some patients who, when you look at their skin, their disease is incredibly severe. You may think that the best way to help them is with some systemic therapy, but either the patient is not bothered enough by their eczema or they are concerned enough by potential side effects that systemic therapy is not worth it to them. What it comes down to is this balance of quality of life (QOL) and burden of disease for the patient and their tolerance for any potential side effects that might happen with escalating therapy.
As we add more and more systemic options, we hope that these therapies are going to be safe and well-tolerated. Hopefully, the addition of extra choices will make it easier for patients who do have a high burden of disease. Deciding on the appropriate systemic therapy is all about whether that balance of safety and preference is tipped for the patient—not necessarily about the eczema that we see.
Regardless of how severe a patient’s eczema is, moisturizing regularly and use of topical anti-inflammatory therapy are both still cornerstones of treatment. Even people who have severe AD sometimes improve dramatically with just those measures. But there are many patients for whom topical therapy is not enough. The conversation turns to things such as phototherapy, which is UV light therapy, and systemic therapy, including different pills or injectable medications that work in some way by modulating the immune system to try to get at the inflammation of AD and decrease that inflammation systemically.
Right now, the systemic therapies that we have available are cyclosporin and methotrexate, which are the two best-studied older medications for AD. Azathioprine and mycophenolate are two other immunosuppressive medications that we sometimes use. Dupilumab was the first biologic therapy approved.
We are lucky now that we have several new medications that seem to be coming in the near future. Some of them are injectable biologics, like dupilumab, and others are oral medications called Janus kinase (JAK) inhibitors. While right now the choice is between the older conventional agents and dupilumab, soon there will be all sorts of other medications added to that decision-making process.
The choice of whether to move to some therapy beyond topical treatment is complicated and patient-dependent. There are some patients who, when you look at their skin, their disease is incredibly severe. You may think that the best way to help them is with some systemic therapy, but either the patient is not bothered enough by their eczema or they are concerned enough by potential side effects that systemic therapy is not worth it to them. What it comes down to is this balance of quality of life (QOL) and burden of disease for the patient and their tolerance for any potential side effects that might happen with escalating therapy.
As we add more and more systemic options, we hope that these therapies are going to be safe and well-tolerated. Hopefully, the addition of extra choices will make it easier for patients who do have a high burden of disease. Deciding on the appropriate systemic therapy is all about whether that balance of safety and preference is tipped for the patient—not necessarily about the eczema that we see.
Managing Moderate to Severe Disease With Dr Chiesa Fuxench
When thinking about strategies for managing moderate to severe disease, it is important to understand that the way we think about this disease is changing. We now tend to think of AD as a more chronic, possibly life-long disease, with episodes of flare throughout a patient’s lifetime, versus a disease primarily of children. With this in mind, deciding on how to best address AD as a chronic disease requires us to think about three important factors. First, we want to treat acute flares and bring them under control as quickly as possible to limit progression and potential impact on QOL. Second, we also have to think about what is going to be the long-term treatment plan for an individual patient; once an acute flare subsides, and because we know that they are likely to flare in the future, we need to plan for and try to prevent that event from happening in the first place. And third, we need to consider patient preference and involving them, and their caregivers as needed, in a shared decision-making process.
While the majority of patients with mild AD can expect to obtain clinical improvement and disease control with use of conventional therapies and with environmental and occupational modifications, these types of interventions may not be sufficient for patients who have moderate to severe disease or for patients who have very difficult to control disease despite the use of high-potency TCS. This is the time when we should be thinking about discussing the use of a systemic agent or phototherapy.
When we think about phototherapy, we do know that phototherapy is recommended for patients who have either acute or chronic disease. However, in my experience, if a patient is actively flaring (ie, red and itchy) and I put them inside the phototherapy machine for treatment, oftentimes the patient doesn’t tolerate it well because of the heat and sweat which can exacerbate their symptoms. Typically, in those situations, I try to calm those symptoms down first and then transition them over to phototherapy if I can.
For patients whom phototherapy may not be indicated or not feasible, we can think about systemic therapies. While there are multiple systemic therapies with evidence in treating severe AD, the only currently FDA approved option is dupilumab. In terms of efficacy rates, there are few head-to-head comparisons to determine which treatment modality is superior. From the data available, the options that show better efficacy rates tend to be oral medications, such as cyclosporin or methotrexate, or injectable medications, such as dupilumab.
It is also important to think about the route of administration for systemic agents. Is the patient alright with taking an oral medication or self- administering an injectable? Further, the side-effect profile across all these systemic medications varies. Some are known to be more immunosuppressive or affect renal function more than others. Therefore, patients may not be able to be on a particular systemic for a long time, such as with cyclosporine. In the case of dupilumab, though it is very well-tolerated by most patients, we do have to remember that injection site reactions have been reported along with higher rates of conjunctivitis. Bloodwork monitoring can be an important factor in choosing a systemic agent as well. For oral medications, there is more frequent bloodwork monitoring vs dupilumab, which does not require routine laboratory monitoring if the patient is in overall good health.
The International Eczema Council (IEC) released a recommendation on how to advance to systemic therapy in patients with AD, and it nicely summarizes a few of the points discussed so far. Essentially, the IEC recommends examining all these different parts before coming to a consensus with the patient to move forward with systemic therapy.
Do all patients need to follow the same route of failing topical therapy before moving to systemic? I do not think that is fair for every patient. There are some patients who present with widespread, extensive disease that simply cannot be controlled with only topical agents. In these cases, moving forward with a systemic agent sooner could be the appropriate decision.
Dermatologists should not forget that when examining a patient, we should also ask them about their sleep, itch, QOL, work or school performance, and social life. While the disease may not be as extensive or severe, if a patient says their “mild” disease is significantly impacting their QOL, then we as providers should take a step back and consider reevaluating our assessment of their disease severity. These extracutaneous factors can also move a patient to systemic therapy quicker than a patient who seems to be unbothered by their disease.
Managing the Whole Patient, Not Just the Disease With Dr Drucker
AD can take over patients’ lives in many ways. It could be the itch of the condition making them uncomfortable throughout the day or making it difficult for them to sleep. It could also be that their inflamed, flaky skin makes them less likely to want to socialize or impacts their productivity at work or attention at school. When we treat AD, we must keep these things front of mind, because treating this condition is not about just making the skin clear and calling it a day. Treating AD should be about addressing all of these different issues as part of more holistic patient care. If the patient’s treatments are not addressing their disease burden and improving QOL to the extent that is going to make a patient happy, then we as providers are not doing enough.
We have therapeutic options for every different level of severity. No one treatment regimen is necessarily the best or the only option available for a patient. What may be important for all patients is helping them identify what triggers they may have, if any, that can cause an AD flare. It may be the case that a patient cannot identify any specific environmental triggers or their environmental triggers are things that they cannot avoid (for example, cold weather is a trigger and they live in Canada). There is an important role for identifying triggers, yet sometimes if we focus on avoiding triggers too much, we can end up losing the forest through the trees and miss out on other things that can improve eczema, such as frequent moisturization and using different topical medications.
Shared decision-making is also crucial. Patients can and should take an active role in their care plan. For example, there is no one moisturizer that is best for eczema; our approach to moisturizer recommendations should focus on what the patient is going to use because they like it.
One other element that I think is important to help patients in managing their disease is to decrease the burden of things that we as physicians and as other health care providers are placing on them. The word basic in basic skin care makes it sound like these steps are really easy. Overall, though, we are asking a lot of patients: moisturize a few times a day, put on topical medications, try to do it this time of day, try to do it after the bath, try to identify triggers. These things can be a burden for a patient or a caregiver to manage and incorporate into their life. Anything that we can do as providers to mitigate some of that burden on patients is welcome. One thing that I try to do is to prescribe most topical medications, particularly TCS, as a once-a-day treatment. There is some evidence that once-daily application is just as good as twice daily, and if we can at least get rid of one thing off a patient’s eczema to-do list, I think that’s going to be really appreciated by many patients.
In addition, we always need to be aware of our limitations as dermatologists and do what we can to help our patients with AD and recognize when we need help from some of our colleagues. If a patient has severe asthma, personally, as a dermatologist, I do not want to make treatment decisions that might impact their asthma without also getting the opinion of their respirologist and making sure that we are on the same page. Coordinating care for our patients with a multidisciplinary team can help improve the patient’s outcomes beyond what we can do in our practices.
Building a Foundation for Maximizing Adherence and Outcomes, featuring Erin Foster, MD, PhD
AD is a chronic disease that people have to think about when they have it. It will be on their mind when they apply their treatment, and the patient will definitely think about their AD when they experience an active flare. Because of this, the most important thing that I try to emphasize to my patients is the need for them to understand their disease and be on board with its treatment. As humans, we are all okay with doing hard things as long as we feel like it is worth the desired outcome, and treating eczema should be looked at in the same manner.
Dr Eric Simpson taught me a simple technique that I still use today. In his clinic, when he has an appointment with a patient with AD for the first time, he says to the patient, “This is a chronic disease that’s treatable, but it’s not curable.”
In my practice, I do the same thing with my patients. I try to liken it to something that they already know about, such as diabetes. I explain how diabetes does not have to control your life, but you have to integrate it into your routine with lifestyle changes and medications. I also pick something that I know everybody does at least once a day, maybe twice: brushing our teeth. I say to my patients, “Medicines for AD should be like brushing your teeth, because it’s just daily maintenance of your skin, the same way that you’re taking care of your teeth.”
These conversations go a long way in building a foundation to a good relationship with your patient. If your patient does not trust you, then there will be no patient compliance. I personally like to come to work and feel like I am helping people rather than having a struggle with my patients. I figured out early on that the best way for me to do that was to improve my relationship with the patients.
There are a couple of simple things you can do to help improve your patient relationships. You can sit down when you are in the room with a patient, which has been shown to give the impression that you are spending more time with them, even if you are still in a rush. It has also been studied that physicians interrupt their patients after 11 to 23 seconds of a patient speaking. There was a great JAMA commentary that basically said these interruptions are when we miss out on the context of a patient’s disease. For example, this is when you miss out on why the patient is not able to afford their medicine or what they have not done well in the past with other providers. Those are simple things that you can gather at the beginning of the visit, in those first 30 seconds of the patient interview, by just sitting there and not speaking.
Another important factor is having an empathetic relationship to understand the patient’s background and experiences. One thing to realize is that patients have been putting all sorts of topical products on their body to try to relieve their AD symptoms before they have come to your office. They may be frustrated or discouraged. It can be helpful to remind them, or tell them for the first time, that a TCS is not going to relieve the itch the day that they use it, but it should be used repeatedly and as prescribed to see improvements. This conversation can be a good way of managing expectations as well.
The second one is close follow up. Dr Jon Hanifin taught me this. He calls patients 2 weeks after seeing them to make sure that they are fine, and in some cases, he even has them come back into the office. It can go a long way into building trust with the patient by showing your support in their eczema journey.
Something that I always do is provide written instructions so the patient has a reference point from me when they are at home. In addition, I also recognize that patients are going to search the internet for more information. I do not tell them not to search, but I do give them the right resources that I want them to see, such as content from the National Eczema Association. We want to give our patients accurate information about AD, because otherwise, they may find inaccurate recommendations, and that will not be helpful for our relationship.
In terms of shared decision-making, there is a very easy, quick way to do this. When speaking with your patient, state, “There is a decision that needs to be made. Neither of us can do it alone. I have this medical knowledge, but you are the patient. It’s your skin, and so we need to do this together.” This invites them to act as an expert on their disease. We also know from a lot of research that patients want to share decisions with their providers, and we know that, from experience, this can make them more invested in their care and improve outcomes.
I always follow up this initial statement with telling the patient, “You can always change your mind. We can increase or decrease the dosage or the strength of the medicine, but this is your choice, because it’s your skin. You have to live in it, and this is the decision that you have to be comfortable with.” It does not take very long, but setting that context works really well with patients. They are very happy to hear that. It fits with their lived experience, and it certainly makes for a much more satisfying visit and much more satisfying follow up as well.
