In this 6.5-minute video, Zelma Chiesa Fuxench, MD, MSCE, describes her go-to treatment plans for patients with moderate to severe atopic dermatitis in-depth, including weighing the risks and benefits of systemic treatment options such as phototherapy, immunosuppressants, and advanced therapies.
Dr Chiesa Fuxench is an assistant professor of dermatology at the University of Pennsylvania.
Transcript
Dr Chiesa Fuxench: When thinking about strategies for managing moderate to severe disease, it's important to understand that when we think about atopic dermatitis, the way we think about this disease is changing. We tend to think more of it as a more chronic disease, with episodes of flare throughout a patient's lifetime versus a disease that's primarily of children.
The discussion is still out there, but most of us do tend to think of atopic dermatitis as a chronic disease. When you're thinking about treatment options for atopic dermatitis, there are three very important things to consider. One is, you do want to treat the acute flares. You want to bring them under control as quickly as possible to limit progression and potential impact on quality of life.
You also have to think about what is going to be my long-term treatment plan for this patient. Because once the flare subsides, you know that they are probably going to flare up again in the future. We don't know when that will happen, but we need to plan for that.
I also take into account again patient preference, because again, it doesn't matter if I think something is great or not, but if my patient is not on board with me, we're not going to go anywhere.
While the majority of patients with mild atopic dermatitis can expect to obtain clinical improvement and disease control with use of simoleons and conventional therapies such as topical corticosteroids or calcineurin inhibitors and also 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.
That's when you move into the discussion about using a systemic agent or potentially phototherapy. When we think about phototherapy, we do know that phototherapy is recommended for both patients who have acute and chronic disease.
One of the points to consider with phototherapy treatment is that, my particular experience has been that if a patient is actively flaring, meaning it's very red and itchy, and I put them inside the machine for treatment, oftentimes they're not able to tolerate it well because it gets so hot, and they're so sweaty, and this will tend to exacerbate their symptoms.
Typically, I try to calm those symptoms down and then transition them over to phototherapy if I can. In those types of patients where phototherapy may not be indicated or it's not feasible, then we can start to think about systemic therapies.
There are multiple systemic therapies that we can choose from. They're not approved by the Food and Drug Administration for use except for dupilumab. In terms of efficacy rates, there is not a lot of studies doing head-to-head comparisons in terms of which treatment modality is better. From the data that we have available, the ones that showed the better efficacy rates tend to be oral medications such as cyclosporin or methotrexate, or injectable medications such as dupilumab.
It's also important to know that when you're selecting any of these types of systemic treatment options, you do need to think about the route of administration. Is the patient OK with taking an oral medication? Is the patient OK with using a needle that they can administer at home? Also, side effects. The side effect profile across all these systemic medications will vary. There are some known to be more immunosuppressive than others. There are some that tend to affect renal function more so than others.
Therefore you can't be on this for a long time, such as the case of cyclosporine. In the case of dupilumab, even though it's very well tolerated by the vast majority of patients, you do have injection site reactions reported as the result of the injection, and also higher rates of conjunctivitis that is still being explored. Those are things to think about.
Bloodwork monitoring. How often does the patient need to get bloodwork done when taking these types of systemic agents? For oral medications, there is more frequent bloodwork monitoring versus in the case of dupilumab, we don't recommend any other bloodwork monitoring if the patient is overall healthy. Again, this will depend on patient's comorbidities and other medical history, but for the most part, it is not required. The International Eczema Council did put out a recommendation, a decision-making paper on how to advance to systemic therapy in patients with atopic dermatitis. It does summarize a few of the points that we've been discussing so far. Once we look at all those different parts that are always moving, then we come to the consensus of saying, "OK, let's move forward with systemic therapy."
Do all patients need to follow this same route? That you need to do topical first and try to get them under control that way and then move over to systemic therapy. I don't think that's fair for everyone. There are some patients that have so much extensive disease and so much disease spread in that we don't think that we can control this with topical corticosteroids, then the decision is made to move forward with systemic agents.
When you're examining the patient, it's not just looking at the extent of the disease, how inflamed it is, but also asking your patient, are you sleeping well? How is your itch? Can you provide an estimate? Is this impacting your quality of life? Are you able to function at work, to go to school? Are you establishing any social relationships, and those kinds of things.
If I see that this disease, even though it might not be as extensive or I might not think it's as severe. If a patient does say, "You know what? It's impacting my quality of life. I have not been sleeping for the past week. I cannot stop scratching." Maybe this is the type of patient where I would say, "OK, let's take a step back," and we'll probably move to systemic therapy quicker than maybe a patient that has more mild impact on quality of life.
