What should dermatologists do when topical therapy and basic skin care is not enough to alleviate the signs and symptoms of atopic dermatitis? In this video, Aaron Drucker, MD, SCM, FRCPC, discusses what tools and options are available to helping patients overcome their moderate to severe eczema.
Dr Drucker is a scientist at the Women's College Research Institute; a dermatologist with the Women's College Hospital; assistant professor, division of dermatology, department of medicine, at the University of Toronto; and an adjunct scientist of ICES in Canada. He also serves on the Council Executive Committee of the National Eczema Association.
Transcript
Dr Drucker: Regardless of how severe a patient's atopic dermatitis or eczema is, moisturizing regularly, topical anti-inflammatory therapy are all still cornerstones of therapy. Even people who have severe atopic dermatitis sometimes improve dramatically with just those measures, moisturizing and topical steroids.
Whenever a patient is having a severe flare of atopic dermatitis or it's new onset of a really bad atopic dermatitis and they haven't had a good trial of those topical measures, that is always, for me, the first thing that I go to. Sometimes they are enough, even in patients who are covered head to toe with eczema.
There are a lot of patients who topical therapy is not enough, where just moisturizing, using their topical therapy regularly, being incredibly adherent to their treatment plan just doesn't cut it. Then the conversation turns to things like phototherapy, which is UV light therapy and systemic therapy, that's usually different pills or injectable medications, biologic medications that work in some way by modulating the immune system to try to get at the inflammation of atopic dermatitis and decrease that inflammation systemically.
Right now, the systemic therapies that we have are cyclosporin and methotrexate, which are the two best-studied older medications for atopic dermatitis. Azathioprine and mycophenolate are two other immunosuppressive medications that we sometimes use. Dupilumab was the first biologic medication approved.
We're lucky now that we have all these new medications that seem to be coming. Some of them are biologics, like dupilumab, and then other medications what are called Janus kinase, or JAK, inhibitors, that are given in pill form rather than injection.
While right now the choice is between these 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 want to help them and you think that the best way to help them is with some systemic therapy, but either they're not bothered enough by their eczema or they're concerned enough by potential side effects that it's not worth it to them. What it comes down to is this balance of quality of life and burden of disease for the patient and their tolerance for any side effects or potential side effects that might happen with escalating therapy.
As we're getting more and more systemic therapy options, we hope that they're going to be safe and there are not going to be a lot of safety concerns with those medications. Hopefully, that choice will be easier for patients who do have a high burden of disease. They won't have to worry so much about side effects.
It's all about whether that balance is tipped or not for the patient. It's not really about the eczema that we see. Although, of course, that can factor into the decision-making, it's more so about how much is their eczema impacting them, and are they not seeing the results that they should be seeing with just topical therapy.
