Treatment Burden and Quality of Life in Atopic Dermatitis

Raj Chovatiya, MD, PhD, is assistant professor of dermatology at the Northwestern University Feinberg School of Medicine in Chicago, IL. He also directs the Eczema and Itch Clinic where he focuses on chronic inflammatory skin disease, particularly atopic dermatitis and eczema, but also other chronic inflammatory conditions like psoriasis and hidradenitis. In this video Dr Raj Chovatiya discusses frequently updated literature surrounding AD treatment and patient quality of life. 

Transcript:

Dr. Chovatiya: One simple thing that we all learn about in medical school, and sometimes for whatever reason, I find myself forgetting about it too, but it's important, simply reviewing and discussing the medication and treatment plan at every encounter with your patient. Whether they're relatively clear, whether they're severe.

One area that physicians contribute to the patient burden across medical specialties—dermatology and atopic dermatitis are no different—is polypharmacy. Deprescribing sometimes can be as powerful as adding on new treatments for patients.

For example, I've had patients referred to me in my clinic who've been taking, let's say, a daily antihistamine for years as an adjunct treatment approach for their atopic dermatitis.

If you were to take a look in the literature and across guidelines, they would say that this is not an effective approach outside of specifically for the treatment of various allergic comorbidities or, in select situations, night-time sleep disturbances.

In this case, you've identified one treatment that's pretty easy to eliminate, that, by evidence, isn't doing much, and you're simplifying their life and reducing the adverse events that potentially could come from chronic use of an antihistamine—grogginess, confusion, memory issues, and a bunch of anticholinergic effects.

In addition to the treatments that we prescribe, when you review the treatment plan and the medication list, you learn other things that patients are doing that maybe have not come up or are not things that you are necessarily recommending.

Patients look for relief in a variety of ways, whether it be other medical providers over-the-counter products, even complementary or alternative medicine. This can get expensive. This can further add to treatment burden.

Unless you take the time to review risks, benefits, and medical evidence behind some of these choices, you're going to miss a really important piece of the puzzle.

Another pearl I'd say, and this goes in attention with this one, do the best you can to stay up to date on any major changes in therapeutic management of atopic dermatitis.

For years, we got used to the fact that there's only certain options out there, especially for people that needed higher levels of therapy. Now, it's like a new thing that's coming out every day. We have a lot of options and more to come.

It's important to understand which patients would benefit most from step-up therapy and not be afraid to have that discussion with them, or balancing risks and benefits for doing that. It's easy, let's say in one sense, to keep swapping in and out topical agents. Perhaps the adverse events are lower.

At a certain point, when somebody's list becomes extremely long of all the things they've tried and they're using so many things, at that point, it's time to start thinking about ways that you can simplify life, improve quality of life, and try to find treatment options that are more efficacious.

Finally, I touched on this earlier, but understanding all the different clinical domains of atopic dermatitis. I'm not focusing on any one or two. Oftentimes, as dermatologists, we treat based on what we've seen.

Initially, when someone was to come into clinic for atopic dermatitis, you would quickly assess them, take a look at their skin getting a good idea of how the severity looks to you, and make your treatment decision based on that way.

There's a lot that you miss if you don't specifically let the patient talk about what's been going on. That's definitely going to change your treatment. For instance, there's a lot of people that, just by visual examination, look fairly clear.

You might think that this person is pretty well-controlled. Unless you ask the right questions, you might find out that they have a more itch-dominant phenotype of atopic dermatitis and they're severely itchy all the time despite the fact that their skin looks clear.

That's totally going to change how your treatment might work. Similarly, someone might look completely clear when they come in to see you, but if you ask them about how their flares work and when their atopic dermatitis is the worst, it might be only in the summertime, and you're seeing them in the wintertime.

In that case, your treatment selection might be different for, "OK, I don't need to keep them on something necessarily that higher-level year-round, but I need to focus on the time where the atopic dermatitis is going to be worse."

Sometimes, going beyond what you see can help for you to tailor the treatment directly to the patient and not make things too burdensome.

The most important tool we have as dermatologists in general, but especially when it comes to our atopic dermatitis patients, is shared decision-making. It's so important to work together with your patient to craft a plan that's efficacious, safe, feasible, and aligned with individual goals.

One-sided plans oftentimes don't work. If I just tell somebody, "This is what you're going to do," unsurprisingly, it's not necessarily always going to be carried out that way. That's because everybody has different things they value. Different ways that they can carry out treatment plans.

You have to figure out something that works, because a treatment plan that maybe isn't the most optimal but is more practical might be one that someone is better able to stick to. I'd say that it depends situation to situation, so you need to have that discussion with your patient.

Especially now, with so many new treatments on the horizon, it's going to be a more involved conversation with your patients in trying to determine what is important to everybody when it comes to their eczema.

The other thing I'll mention, and I touched on this earlier, is that treatment plans can change, and that's OK. Atopic dermatitis is such a heterogeneous disease with a different course and impact, and things can change over time. Therapeutic decisions should be as dynamic as the disease itself.

Oftentimes, we get caught in this idea of, "This is the eczema plan. Stick with it." Somebody comes back, "OK, things are doing OK. Stick with it." Definitely, based on how activity changes over time and what symptom or quality of life look like, it's OK to change things around.