Lindsay Strowd, MD, on the Challenges of Treating AD

Lindsay Chaney Strowd, MD,  section editor of the Atopic Dermatitis Centers of Excellence and assistant professor of dermatology at Wake Forest School of Medicine in Winston-Salem, NC, reviews the challenges of treating and managing atopic dermatitis in the United States, along with some tips for how dermatologists can address these in their practice.

Transcript

My name is Lindsay Strowd and I’m an assistant professor of dermatology at Wake Forest University School of Medicine. Today, we’re going to be talking about some of the challenges for treating and managing atopic dermatitis in the United States.

Atopic dermatitis is a disease state that we see relatively commonly in the dermatology environment. It is a condition that has received a lot of recent attention as we’ve had some novel therapies that have recently come to market, which are changing how we treat and manage this condition.

There remain a lot of challenges for treating atopic dermatitis, both in our pediatric and in our adult patient populations. Some of these challenges include properly identifying patients that have atopic dermatitis and making sure that we have the correct diagnosis and are not mistaking another disease for atopic dermatitis.

Another challenge can involve engaging the patient in helping to make treatment option decisions, and the best management for their underlying disease.

Another challenge can be getting coverage and insurance reimbursement for those medications and treatments that we want to use in each individual patient and navigating the sometimes tricky waters of higher authorization and insurance approval.

Another challenge can involve dealing with the comorbidities that come along with atopic dermatitis. We’ll talk about those later on in this podcast.

As you can see, there’s many challenges for diagnosing and managing this disease in our patients. Sometimes, challenges are an opportunity for us to improve the lives of our patients and to tackle this complicated disease head-on.

It is important to make the correct diagnosis when you’re considering a patient that may have atopic dermatitis. Oftentimes, patients with atopic dermatitis may initially see providers that may not be quite as familiar with this disease process, such as primary care providers or pediatricians.

It's critically important for us, as dermatologists, to work collaboratively with our primary care providers and colleagues, to help them better understand how to recognize atopic dermatitis and help them initiate some basic treatment options before we see the patient in our own clinic.

One way dermatologists can improve access to care for our patients in general, including those with atopic dermatitis, would be the use of teledermatology.

Teledermatology is becoming more widely utilized in many different states, both as the store-and-forward type of teledermatology, as well as the live interactive teledermatology, whereby primary care physicians can contact specialists, such as dermatologists, and ask for their opinion on patients and some basic treatment guidelines that they can initiate before the patient comes to see us in clinic.

This may help funnel patients that have more moderate to severe disease into clinic more quickly, as well as help patients with mild atopic dermatitis avoid extra doctor’s visits by allowing their primary care physicians to provide most of their treatment.

Anyone who provides clinical care to patients has likely encountered a scenario where they prescribe a medication for a patient, only to get a message back from one of their office staff that this medication cannot be approved without a prior authorization.

Prior authorizations are now a fairly ubiquitous part of providing medical care in the United States, and unfortunately, can take a lot of time and effort, both on the part of the office staff, the physician, and the patient, in order to get medications approved.

Atopic dermatitis is no exception. Some of these newer medications, and in fact, even some of the older medications that we’ve historically used to treat atopic dermatitis, still can be involved with the use of prior authorization.

The American Academy of Dermatology has some information on their website to help, including a way to generate a prior authorization approval letter that you can send directly to the pharmaceutical companies, that is outlined in a template format, which makes it very easy to fill out.

Some of the drug companies that sponsor some of these newer medications can also have resources available for patients, via patient assistance programs or coupon cards, that can help lower the cost of some of these medications, as well.

It’s important for us to discuss the cost of these medications and the process for getting them approved with patients at the time of the office visit, so that patients can understand and be aware of some of the barriers and some of the delays that may be associated with getting them a proper medication.

When we talk about atopic dermatitis, we should consider all of the diseases that go along with the diagnosis and management of this condition. What we know from prior literature is that patients that are diagnosed with atopic dermatitis often have other disease states as well.

These can include other atopic diseases like allergic rhinitis and asthma, but can include some other diseases you may not initially think that would go hand-in-hand with atopic dermatitis.

These can include things like chronic sleep disturbance, depressions, anxiety, other dermatologic conditions such as contact dermatitis, and even some more controversial associated conditions such as cardiovascular disease, and potentially, even lymphoma or lymphoproliferative diseases.

As a dermatologist taking care of these patients, we owe it to our patients to do a very thorough history-taking exercise with them, to identify any of these other comorbidities. Addressing these comorbidities can help us in terms of getting our patients onboard with our treatment plans, and making sure that we’re attending to the whole patient and not just treating their disease.

Unfortunately, mental health is a big issue in patients with atopic dermatitis. It’s important to recognize and treat underlying mental health issues such as depression and anxiety, as these can negatively affect compliance with treatment, as well as can have a great impact with patients and their social relationships with their caregivers, their peers, and their spouses as well.

When we talk about the treatment of atopic dermatitis, historically, we have treated this condition with topical medication. Medications such as emollients, topical corticosteroids, and topical calcineurin inhibitors are some of the medications that we use most commonly in treatment of mild and moderate atopic dermatitis.

What’s exciting for us in dermatology is that we have some newer medications that have been approved in the past couple of years that have started to revolutionize how we treat this disease.

The newest topical medication to be approved is topical crisaborole, also known as Eucrisa. This is a topical boron molecule that’s FDA-approved for patients, ages two years and older, with mild to moderate atopic dermatitis. It provides us with yet another topical therapy that’s a non-steroidal option that is safe to use in sensitive body areas such as intertriginous sites, as well as on the feet.

Perhaps one of the most exciting treatment to become approved recently is dupilumab, also known as Dupixent. Dupilumab is the first biologic that’s FDA-approved for atopic dermatitis, and is currently approved for children, ages 12 years and older, as well as adults, with moderate to severe atopic dermatitis.

Dupilumab has shown in pivotal studies to reduce both the itch, as well as the overall disease severity in patients with severe atopic dermatitis. This medication, overall, has been very well-received by the dermatologic community, and has had fairly minimal safety risk associated with this medication.

It is an injection medication. If you’re considering using this in a patient with atopic dermatitis, you need to discuss how to properly administer this medication. It’s oftentimes helpful for providers to give the patient the first injection, if you have it available in your office, to properly demonstrate how to use this medication and where to do the injection.

It’s important to educate patients on exactly what medications, such as dupilumab, are doing for their skin disease. This medication is an IL-4/IL-13 blocker, so it’s blocking some of the main, key inflammatory pathways that we know are critical in the development and maintenance of atopic dermatitis.

The upside is that, as a result, patients oftentimes get significant and fairly quick and rapid improvement in their overall skin disease, once they start a medication such as dupilumab.

We can look to the future, as there are many other biologic molecules currently under investigation for use in atopic dermatitis. This feels like the very beginning of an exciting period of time in dermatology, where we will have many different options that are specifically designed to treat this very complex and burdensome disease, for both our pediatric and our adult patients.

In conclusion, I think this is a very exciting time for those of us that take care of patients with atopic dermatitis, as we’re beginning to have newer and more effective treatment options come to market. I think it'll be fascinating to see how the therapy changes over the next 5 to 10 years as even more novel therapeutics enter the market, and how we can better improve the lives of these patients.

Thank you for listening, and I hope you’ve enjoyed this podcast.

For more articles, visit the Centers of Excellence Atopic Dermatitis