Matthew Brunner, PA

 As we come to a close on this discussion, I sincerely appreciate all 3 of you taking your time to talk about atopic dermatitis; you’re all seasoned, work in well-known clinics, and are definitely leaders among your peers. Do you have any pearls, hints, words of encouragement, or topics that you’d say make sure you discuss with your patients and teach colleagues without your wealth of experience? Whether you’re talking about triggers, hints for adherence, or talking about all the features and facts associated with the disease. Everybody pick something and tell me the one thing that you must say, to make sure that these youngsters who don’t know everything, I know that I could pass along to them. Matthew, what would be your thing that you would tell new PAs [physician assistants] or colleagues who haven’t seen as much atopic dermatitis as you have?

 I go back to the thing we learned when we were in our training: listen to your patient, they will tell you what’s wrong with them. Part of that is taking a good history, talk to them about their family, their personal history, things like asthma, hay fever, and sinus allergies. I always ask patients if pollen bothers them when the pollen season is bad. We have a terrible pollen season here in Georgia. I think those things help you. “Have other family members had rashes like you?” Talk to them about their experience. Sometimes the elderly patients have forgotten their history of childhood, but they’ll say, “I had a brother who had asthma.” Talking through those things and getting that history up front, that’s been the most valuable thing for me in terms of differentiating between a patient with atopic dermatitis and a patient who may just be having a single episode of eczema.

 My big thing is, we just talked about the future of 2023 and all these exciting things, to not be afraid to have a low threshold for topical therapy. Because we just spent an hour talking about how eczema is a systemic disease, so you wouldn’t treat diabetes with a topical, you would treat diabetes with an oral therapy. That’s how we look at psoriasis, and that’s how we’re going to start looking at eczema. If somebody is not responding well with topical therapy, we need to discuss and educate our patients and their parents on what else is out there because we don’t want these patients to suffer, and they truly do suffer. Itch and infection are horrible, and constant antibiotics, oral steroids, and topical steroids are not good for our patients, and long term we know that’s not good as well. We have many safe options in the biologic space and potentially in the oral space such that we are OK to have a low threshold on when it’s time to get to that next level.

 My pearl, first, for NP [nurse practitioner] or PA colleagues who are novices, is to get excited about treating atopic dermatitis. It may not be the new sexy disease on the page right now, but it is a very rewarding career to treat these patients and become the expert in your clinic for managing atopic dermatitis. Your ability to transform patients’ lives, treat these patients, and see them grow and thrive is extraordinary. Feel comfortable with this disease, become involved in your national societies, go to meetings where there are atopic dermatitis experts lecturing, and become comfortable in your algorithm and in your treatment plan. There are many resources available for you with up-to-date information so that you can become comfortable and an expert in managing atopic dermatitis.

My pearl for [working with] patients is to teach them that you are excited about treating them. When I walk in the room with a new patient with eczema or even psoriasis, I tell them how excited I am that they’re here and that I’m going to be their partner through this entire disease. Then I ask them this pivotal question, “What is it about this disease that is keeping you from finding joy in your life or living your best life? If you give me time and your trust, I’m going to help you find that joy. I’m in this with you and partnering with you to help you live the best life that you can.” I think those are 2 important things that patients want to hear from us as dermatology providers and for us to recognize within our patients, that this disease can be consequential for them and their happiness, and their ability to thrive in their lives.

 One thing I always think about that’s really important is to help them understand that it’s not their fault. There are triggers, we know it can be pollens, it can be animal dander. There are certain things that can trigger patients with atopic dermatitis that you might have some control over, but this is a disease. It’s a disease that involves a lot of components, a poorly functioning barrier, and an inappropriate cytokine response to triggers, but it is a disease. It’s not their fault, so they must understand that they’re not doing anything wrong.

For my colleagues, I would say practice evidence-based medicine, don’t get caught up in people saying, “But if I don’t eat this, or I use this CBD [cannabidiol] oil, or I use whatever, I’m a little better, or this helps.” They’re searching, and you have to say, “Look, here’s the deal, I know a little about that, but I can tell you what the science and the evidence say.” We’ve got excellent data now that explain what this disease is, what’s going wrong, and how these medicines are specific to try to treat it. So know your medicine. If you’re going to prescribe it, and diagnose and treat these patients, medicine is a wonderful thing, so make sure you really understand that.

Thank you for this insightful discussion and thank you to the audience for watching this 

 presentation with Alexa, Matthew, and Lakshi. I hope that you have learned something and that you will take this information to heart the next time you see a patient and you start thinking this child could have atopic dermatitis. As Alexa says, have a low threshold for moving along and getting them pediatric-approved therapies and get them going. You’re going to change some lives and be heroes to these patients, and really make a big difference. Thank you.

Videos

Alexa Hetzel, MA, PA-C; Lakshi Aldredge, MSN, ANP-BC, DCNP, and Matthew Brunner, PA, share practice pearls and clinical management tips for the care of pediatric patients with atopic dermatitis.

Practice Pearls for the Management of Atopic Dermatitis 

 What do you think are going to be the big things that we’ll talking about in 2023 about atopic dermatitis? I know there’s talk about looking at earlier intervention, using any special populations, and then some prevention, if we can intervene and prevent some of the comorbidities. What do you think? What does your crystal ball tell you for the next year or two?

 I think the dermatology field is going to be getting their hands around the systemic Janus kinase inhibitors. We have upadacitinib approved now down to age 12 for atopic dermatitis. We don’t yet have abrocitinib approved for that age group, but we have some new PDE4 inhibitors topically that are under development. Arcutis [Biotherapeutics, Inc] is working to bring roflumilast to market, and then there’s a Japanese firm that’s working on difamilast. There’s a lot of interest in how we combine these therapies. I think some of us are starting to work with that. To your point, Melodie, not every patient is a dupilumab responder, but is there a safe way to combine these therapies where patients are getting benefit, but maybe are not completely clear? There are many of us out there, and that’s one of the things we do really well in dermatology, we look at how these drugs can be used in combination and how we can achieve synergies for patients by mixing and matching. Obviously, a lot of the labels indicate they haven’t been studied together and they may not be safe to be used in conjunction, but I think some of us out there are looking a little deeper at the science of how they work and understanding that it’s probably safe to combine some of these agents.

 I was going to add to Matthew, especially when you have different combinations, if you have dyshidrotic eczema, it doesn’t always respond to anything. If you have somebody who has full body eczema and then dyshidrosis on their hands and feet, that combination therapy can be huge for us to look into because I think that’s itchiest part of it all.

 That’s a good point. Atopic dermatitis is not sometimes the only type they have. They can have atopic and dyshidrotic, or atopic and contact [dermatitis]. That’s one of the things that we must speak to, it’s important. Lakshi, what were you going to say?

 If I had a crystal ball and looked at 2023 and 2024, what we’re also going to understand are the comorbidities associated with atopic dermatitis. We have a lot of data and literature about comorbidities in psoriasis, which we originally thought was only a skin condition. I think our understanding of eczema and its potential comorbidities is going to expand. I think that we’re also going to have a lot of differences hopefully in the way we treat patients with some of the existing and newer treatments as far as the frequency of use. My hope is that we’ll have an effective treatment that’s maybe used once or twice or even 3 or 4 times a year only, but can help control flares very effectively. So a decrease in the frequency of use, so that we have lovely long-term remission with very infrequent use. I hope that will also be an important factor.

I also hope that we’ll have some affordability of these treatment options for communities of need, and for those folks who perhaps have ethnic, cultural, or other considerations, with our understanding of what works better for those different skin types, we could do a test potentially that shows which treatments or cytokines would be more effectively targeted in certain individuals. So instead of having them go through multiple treatment therapies, we can identify and say, this is the treatment that’s going to be giving you the best control, less variance in disease, and more focused therapy.

Experts in dermatology hypothesize about the next round of treatment disruptions and their hopes for the future of atopic dermatitis management.

Future Directions for the Management of Atopic Dermatitis

 Are any of you aware of the new topical therapies coming down the pipeline for pediatric populations? Have you looked at those at all yet?

 Yes. Our office is in the clinical trial for topical tapinarof for AD [atopic dermatitis]. I have a 3-year-old [patient] who’s in this study, and he had about 80% BSA, had a 3 score on the PGA [Physician Global Assessment], and it was bad. Poor mom she was like, “My kid, I need help.” We put him in the study because, our office doesn’t take the insurance, but she brought him to us because his atopic dermatitis was so bad. A week later he was, I would say 60% better, it was incredible. He started singing Black Sabbath, and it was funny, he’s like, “I am Iron Man.” You could tell the mood of this child had changed completely from a week of topical therapy. It’s exciting to see all these different things that we have that are coming and actually work.

 In dermatology, we know topicals. It’s been hard for us to get away from topicals, and now that we have topical options, it’s how much and how to use. We are trained for that, and we can teach our colleagues in pediatrics and allergy. We’ll definitely be speaking about that. Have any of you read or heard anything else about some of the other topical and systemic therapies being evaluated in the under-18 crowd? What does it mean to have more options? What do you think about having these additional options? Hopefully at least part of them will be available.

 It’s exciting because topical therapy has taken a huge backseat in the world of dermatology with the emergence of all the biologic therapy that has happened in the last 20 years. In the last 5 years we’ve had research studies and new agents in the topical realm, which has been exciting because not all patients need a systemic agent because they’re not necessarily moderate or severe but are starting to get there. For whatever reason, topicals seem to be the most appropriate option. It’s nice to have those agents. Alexa mentioned the aryl hydrocarbon receptor agonist as a topical target, which is exciting because it’s nonsteroidal and seems to have excellent efficacy with a very safe profile. We have several other topical treatments that are coming down the line, and we don’t know the target specifically because it’s a number in the research clinical trials, but nonsteroidal looking at more of the inflammatory markers and targeting the barrier disruption portion of pathogenesis.

It’s exciting to have this time in dermatology where there’s a resurgence, a renewed interest, in topical research studies. I’m grateful for pharmaceutical companies that are putting the time and effort into creating topical treatments because this is the bread and butter of dermatology. Topical management of skin conditions definitely has a place, not only in our hearts, but on our skin because it’s what we do well, and it’s what patients want because it provides almost immediate relief. As you mentioned, Mel, itch is the heartache of most dermatologic conditions, but also the pain that comes with ongoing scratching when you have deep excoriations, it can become secondarily infected and painful. To have both topical and biologic therapy that is emerging in the atopic dermatitis sphere is a win for both providers and patients and their families.

 Dupilumab, as efficacious as it’s been, it doesn’t fix everyone, and it doesn’t fix everyone at a 100%. It’s incredibly effective and has changed so many lives, but we need more. I have adult patients who have not done as well on dupilumab as they needed to, and I have started them on some of these newer biologic agents and oral small molecule agents that have come into the market, and they are doing beautifully. We all know that this is a complex disease, and there’s no one therapy that’s going to be the end-all for every patient. In the clinical trials in dermatology, everything’s used as monotherapy. Occasionally you’ll get to use a low potency topical corticosteroid additionally with some of them, but it’s important if you want to clear a person and get them as best managed as possible to have a multitude of options to pick and choose from, so the more the better.

To try to interrupt, to have more agents come to the pediatric population, we want to see studies done as much as possible in adolescents and pediatric patients, with hope that the FDA will be favorable with helping to oversee that. I’d love to have more data about use in pregnancy. Again, we’re talking about drugs in adolescents, and to have more data about that, and more data in all the different races, ethnicities, and different populations of people we see. The better data we have, the better decision-making we can have, and better care we can provide.

Alexa Hetzel, MA, PA-C, and Lakshi Aldredge, MSN, ANP-BC, DCNP, provide insight into emerging therapies and ongoing investigations in the management of pediatric atopic dermatitis.

Emerging Therapies for Pediatric Atopic Dermatitis Management

 The rapid resolution, I think there's some discussion about that. You take that into account because you can use topicals for symptom relief and it still a minimal improvement. Whereas with these new systemic agents that we're seeing in the adult population, and dupilumab in this adolescent population, you can see rapid improvement in itch and scratch, then the disease seems to melt away when you can keep their paws from it. You can't just say don't scratch, it's not that easy. Matthew said long ago you had to learn biofeedback methods to keep yourself from scratching when you get older. As a kid, they can't. Rapid onset is also one of the selling points of these systemic therapies. Don't you agree? Even some of these new topical therapies will be shocking the way that we’ll see improvement with itch quickly.

 That's one of the first things that people are reporting with agents like dupilumab, that immediate cessation itch within the first week or so of starting. Sometimes the skin's a little slower to change, just because the skin must heal, especially if there's a lot of lichenification, but that itch once we can get that under control, I feel like we can heal the skin. It's getting that itch there.

 Itch is one of the most miserable things that we deal with in dermatology. Other orthopedic people deal with pain—rheumatology they deal with pain—and some of our patients have pain, and there are many meds to manage pain, but there's been very few things to manage itch. We would knock them out. You see a lot of people treat atopic dermatitis with systemic antihistamines and we know that it doesn't work. You can knock them out and keep them from scratching for a few hours so that they can sleep, but it's not effective, the itch is miserable. All you must do is have a good case of triggers or something that gives you a good itch, and for while you can see a glimpse into what these children, or these patients, deal with when you're so itchy that you can't be still. It's miserable. I wouldn't wish it on anyone.

Experts in dermatology comment on the impact of treatment response time on pediatric atopic dermatitis burden.

Matthew Brunner, PA

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