Perspectives in Atopic Dermatitis
In partnership with the National Eczema Association, the Perspectives in Atopic Dermatitis (AD) virtual course took place live on February 23, 2023. Moderator Andrew F. Alexis, MD, MPH, vice chair for diversity and inclusion in the department of dermatology and a dermatologist at the Weill Cornell Medicine Center for Diverse Skin Complexions in New York, NY, joined leading experts who shared perspectives on the patient journey, mental health comorbidities, management, and treatment adherence to help address the unmet needs of US adults affected by moderate to severe AD.
The Patient Journey
Brian Kim, MD, MTR, vice chair of research at the Mount Sinai Icahn School of Medicine in New York, NY, presented “Understanding the Patient Journey for Adults With Moderate to Severe AD.” The goal of this session was to examine areas where clinicians can positively affect AD management and treatment outcomes and better advocate for patients with AD to improve their experience through education and multidisciplinary care. Dr Kim noted that the patient journey begins from their first symptoms and moves through diagnosis and initial treatment. For patients with skin of color, the journey may be “more arduous and prolonged.” Multiple treatment pathways for AD can lead to challenges when creating individualized management plans and a lack of consensus on some diagnosis and treatment aspects may make the patient’s journey more difficult. For patients with unmanaged disease, primary care clinicians may not be confident about when to make a referral to specialist care. “Nonphysician clinicians and primary care clinicians may benefit from increased education and awareness of AD, as well as first-line therapies and appropriate referral scenarios. Dermatologists and allergists/immunologists may benefit from increased understanding of and comfort with biologics and immunosuppressants and the ability to address safety concerns of systemic drug use,” Dr Kim suggested.
There are unmet needs when it comes to adult-onset AD, in which many patients are not optimally responsive to currently approved therapies and face a multidimensional disease burden. When patients have inadequately controlled AD, they experience decreased quality of life and the disease can negatively impact several facets of daily living, such as sleep and social/work functioning. Itch is reported as the most bothersome symptom to affect multiple aspects of patients’ lives, and flares are significantly challenging in long-term management. Patients may experience barriers to care, including ineffective or difficult treatment plans, lack of access to specialist care, and delayed treatment due to prior authorization.
Multidisciplinary care can improve treatment adherence and should include addressing psychological aspects and comorbidities. Patients may have fears related to safety of medications, adverse reactions, and long-term effects, and some patients are interested in alternative therapy. Dr Kim indicated that “understanding patient preference for AD treatment can help discussions of shared decision-making.” He continued, “Patients with AD value considering the benefits of treatment vs the risks. Patients may accept reduced efficacy for quicker onset, oral route, or less frequent monitoring.” Advocacy includes raising awareness of how AD affects patients’ lives, ensuring access to affordable and effective treatments, and increasing federal funding for research to better understand AD. Dr Kim concluded, “It is important to define treatment goals in a way that optimizes efforts to achieve harmonization of treatment strategies.”
Mental Health Concerns
“Discussing Mental Health Concerns With Adults With Moderate to Severe AD” was presented by Zelma Chiesa Fuxench, MD, MSCE, assistant professor of dermatology at the University of Pennsylvania Perelman School of Medicine in Philadelphia, PA, who provided strategies for assessing mental health concerns in adult patients with AD. Mental health disorders are real-world comorbidities in AD; patients with AD are 44% more likely to have anxiety and 30% more likely to experience other mood disorders. Adult patients with AD have a two-fold increased risk of depression and a higher prevalence of suicidality, and are more likely to report suicidal ideation. Other psychosocial and neuropsychiatric comorbidities of AD include attention-deficit/hyperactivity disorder and autism spectrum disorders, obsessive compulsive disorder, schizophrenia, bipolar disorder, and eating and sleep disorders. Dr Chiesa Fuxench stressed that “assessment of quality of life is an integral aspect of AD care,” which can be viewed as “3 dimensions of skin disease burden: now, long term, and family/partner impact.” To assess depression and anxiety in AD, clinicians can use self-assessment questionnaires. Dr Chiesa Fuxench recommended a holistic assessment incorporating psychosocial aspects of the patient’s history and disease presentation, keeping in mind the challenges that patients may be facing, such as feeling heard, access to care, and treatment adherence. “Incorporating an assessment of the impact of AD on quality of life may have implications for treatment selection and treatment adherence,” Dr Chiesa Fuxench remarked.
Treatment Considerations
Lindsay Strowd, MD, associate professor and interim chair in the department of dermatology at the Wake Forest School of Medicine in Winston-Salem, NC, presented “Treatment Considerations for Adults With Moderate to Severe AD,” with a look at the latest therapies for moderate to severe AD, their potential adverse reactions, and assessing the risk-benefit ratio to provide individualized care. Currently, the US Food and Drug Administration-approved medications are tralokinumab-ldrm for adults only and dupilumab, upadacitinib, and abrocitinib for adults and children of various ages. When choosing a medication, dermatologists should consider the patient’s age and previous treatments, insurance coverage and access, comorbidities and contraindications, and preferences and adherence. “For some patients, taking a pill every day is vastly preferable to doing a self-injection medication whereas other patients highly prefer doing an injection every couple weeks as opposed to taking something by mouth every day. The required ongoing lab monitoring with some of these medications can also affect patient preference and adherence to treatment as well,” Dr Strowd pointed out. Because there is no one medication that fits every patient, it is important to educate patients about the available options and engage in shared decision-making.
Improving Treatment Adherence
“Improving Treatment Adherence Among Adults With Moderate to Severe AD” was presented by Vivian Shi, MD, associate professor in the department of dermatology and director of clinical trials at the University of Arkansas for Medical Sciences in Little Rock, AR. Dr Shi began by discussing the World Health Organization’s 5 dimensions of adherence and highlighting the difference between primary adherence, which pertains to medication refill, and secondary adherence, which is the correct administration and continuation of the prescribed treatment. Adherence continues to be a problem in the United States, with a median adherence rate of 50% for patients with chronic conditions and an annual cost of non-adherence of $100 to $250 billion. “There are 3 hurdles to jump through when treating chronic conditions like AD. First, you have to get patients clear. Afterward, it is a lot of cheerleading and consistency to keep their disease clear, and at the end to keep it up,” Dr Shi stated.
Setting realistic expectations is the key to adherence and patient trust. Patients should know that although there is no cure for AD, the treatment regimen will improve quality of life by controlling the disease. Designing a treatment regimen is “easy to enter, but hard to master.” The pillars of the therapeutic toolbox for AD are calming inflammation, repairing the skin barrier, restoring the skin microbiome, and improving itch and quality of life. The regimen can be burdensome, which may lead to nonadherence, so it is important to “pave a path” for the patient with short-, intermediate-, and long-term goals. The first step is stabilization via medications and lifestyle modification, and the long-term focus is on continued improvement via troubleshooting medications and procedures. Clinicians must also keep in mind the patient-related factors that can influence treatment adherence, such as social support, mental health, and comorbidities, among others; condition-related factors, such as chronicity, quality of life impact, visible lesions and quantity of lesions, severity, body surface area affected, and affected area of the body; therapy-related factors, such as complexity and efficacy, dosing frequency, duration, tolerability, administration route, time consumption, cost, and interference with lifestyle; and health care system-related factors, such as insurance, copayments, physician-patient relationship, and frequency of follow-up appointments.
Clinicians should consider using an eczema action plan with patients to standardize and simplify treatment and act as a visual aid of red, yellow, and green to describe daily management, trigger avoidance, and fl are management. To learn how much a patient is flaring and how the regimen is helping them maintain their disease, Dr Shi indicated that she usually asks patients, “In the last 3 month, how many days have you spent in the red, yellow, or green zone?” Another helpful tool is training a medical assistant or registered nurse to be an eczema educator, which can facilitate education and communication in a busy clinic. When treatment plans are simplified; personalized; and accompanied by a written action plan, education, and technology such as apps to provide reminders and track use/efficacy, treatment adherence can be improved.
Visit www.perspectivesmeetings.com to register for the next virtual course, which takes place on July 27, 2023.
