Defining Iatrogenic Burdens in Atopic Dermatitis

Atopic dermatitis (AD) requires a multistep approach to reduce its signs and alleviate its symptoms. However, current AD treatment methods—following a basic but thorough skin care regimen, using different topical medications, administering systemic or advanced therapies—can create an iatrogenic burden on patients. This then can negatively impact patient outcomes by creating barriers to care.

Raj Chovatiya, MD, PhD, is an assistant professor of dermatology at Northwestern University Feinberg School of Medicine in Chicago, IL. He is also director of the Eczema and Itch Clinic at Northwestern. At the 2021 American Academy of Dermatology Summer Meeting, Dr Chovatiya presented the session “Addressing the Iatrogenic Burden of Atopic Dermatitis” alongside Jonathan Silverberg, MD, PhD, MPH.¹ In an interview with The Dermatologist, Dr Chovatiya shared insights from the presentation and what dermatologists can do to adjust and respond when a patient presents with an iatrogenic burden from their AD treatment.

How is the patient’s disease impacted by iatrogenic burden?
Let’s broadly talk about what an iatrogenic burden means. Iatrogenic burden is complications or ill effects that result from medical examination or treatment. In the case of AD, iatrogenic burden could involve treatment plans that are more burdensome to patients than their clinical signs and symptoms, or even adverse events that could occur from clinician assessment or treatment.

Examples include non evidence based care or even well meaning, evidence based recommendations that are sometimes impractical or even detrimental to quality of life (QOL). All of this together can worsen the patient burden of AD.

Is there a difference between an iatrogenic-QOL impact and an iatrogenic dermatosis?
Everything is connected. AD is not a condition where we can choose to focus only on one clinical domain, whether it be skin signs, symptoms, or QOL. When you are assessing the severity of AD and its impact on someone’s life, all of those are important parts of the puzzle and no one is more important than the other. Similarly, when you are designing a treatment plan, you need to consider how it could impact their life in a variety of ways, whether it be QOL, or some type of treatment related adverse event, or the patient’s ability to follow through on the actual treatment plan itself.

So, if a patient presents with an iatrogenic burden, how do you choose what factor to address first?
You cannot fix a car unless you understand how all the parts work together. That is a good way to look at AD. You cannot begin to treat AD until you understand how all the different clinical domains contribute to the overall picture. For example, if I just looked at somebody’s flexural skin, that tells me nothing about symptom burden or disease extent. If I am looking only at the intensity of redness or swelling of lesions in select areas, this doesn’t necessarily tell me about QOL impact. Following treatment, active lesions on the arms and legs do not mean that there is treatment failure; symptoms, QOL, and comorbidities may have improved substantially. All these elements are important when it comes not only to designing a personalized treatment plan but also understanding exactly how AD and treatments are impacting the individual.

Much of the iatrogenic burden associated with AD can be addressed with effective communication and evidence-based shared decision-making. The first place to start is the first thing that we learned in medical school: just listen to the patient. In the case of AD, it still amazes me how much you can learn about symptoms, severity, comorbidities, disease course, and treatment response in just a few minutes without having to say much.

In your practice, do you recommend any trackers or tools for patients to use to give you a better idea of the impacts and presentation out of your clinic?
I find that asking directed, standardized questions can help track a variety of factors and make it easier to follow AD over time. I am a big proponent of patient-reported outcome tools to understand the burden that patients are facing related to their AD. These are validated, easy-to-use measures that can provide great data to objectively compare what goes on between patient encounters.

Often, these questions are as simple as a numerical rating of itch, skin-pain, or direct questions about QOL. The patient’s responses can help us understand changes in severity and allow us to step-up or step-down treatment appropriately and work towards reducing iatrogenic treatment burden.

For example, imagine a patient who used to be completely clear but now has severe AD. They may use five different topical anti-inflammatory treatments of varying strength over the course of a year, along with antibiotics for skin infections, several over-the-counter nonprescription products, and aggressive moisturization several times daily. When you talk to patients like this, they often compare their treatment regimen to a full-time job that places huge limitations on their life. This patient would likely benefit from advanced therapy with systemic, biologic, or phototherapy. While there is potentially going to be a higher risk of adverse events with higher-level therapies, the trade-off is simplifying the patient’s life immensely with more efficacious treatment. It is critical to consider how treatment plans can address QOL impairment in AD.

Reference
1. Chovatiya RJ, Silverberg JI. Addressing the iatrogenic burden of atopic dermatitis. Presented at: American Academy of Dermatology Summer Meeting 2021; Tampa, FL; August 5-8, 2021.