Neal Bhatia, MD

Dermatologists end their discussion on seborrheic dermatitis (SD), highlighting key takeaways for patients and clinicians on managing this condition.

Beyond Skin Deep: Validating and Transforming SD Patient Care

 As we kind of wrap things back around, we’ve all been in practice for a good amount of time. I think we all have kind of a unique perspective on treating patients with seborrheic dermatitis. I’m just wondering, based on the information that you’ve seen, based on your own clinical practice and any clinical trials, if you could think about some kind of a pearl that you would give to our viewers to take home, maybe to make us all a little bit better in our prescribing or our understanding the needs of a seborrheic dermatitis patient. Adelaide, I’m going to start with you, talking about children, is [there] some special way to communicate or [do] you know some special kernel of truth that you’ve learned in treating a seborrheic dermatitis pediatric patient?

 Well, I think one of the first things I do is I reassure them that it is a treatable problem and that we have tools that will be helpful. And we also have on the horizon some medicines which I’m always proud to say that I’ve had a small role in bringing forward hopefully to the market, and they’ll be coming soon, and I’ll update them as we go along. I think addressing it front and center as a medical problem for which we have treatments and hopefully, soon, better treatments is reassuring. The other thing I say is we take this seriously. I’ve had too many patients come in and say [that] the doctor barely looked then they left the room. “I got a prescription, but then what do I do?” They don’t feel that they’re really feeling validated, so [as] I do often with many disease states I say [that] we take this seriously, and they tell me how grateful they are to hear somebody say that.

 Adelaide, I think I’m taking that home. I want to tell my patients from now, “I take this very, very seriously,” because I think I want to be heard as a patient. I want you to hear what I’m saying and understand that this is important to me even if it doesn’t look like it’s so terrible; I want I want my physician to hear me and understand what I’m saying. James, thoughts on anything that you can give us to take home?

 Just to validate the patient’s concerns and the impact that it has on her life. [Telling them,] “Hey, it’s OK for you to feel this way about your condition. It’s not too trivial, and [I] take it very seriously.” I also thinking establishing that this is a condition that we’re going to be able to treat. It’s not a cure, but we’re going to treat this. We have really good treatments now on the horizon that could really help you get to the place you want to be.

 I think it’s important not to make judgments based on how their seborrheic dermatitis may appear. It’s important to ask patients about their symptoms. In particular, I really focus on asking about their itch. I’ve been surprised so many times. And I think seborrheic dermatitis is just one of those diseases where itch can be a significant burden. You should ask them about it. And now we have the emergence of [a] novel therapeutic that can reduce itch so quickly.

 It’s so interesting because I ask all of my atopic dermatitis patients, talk to me about your itch. That’s so easy because it’s so quick, and I can write it down. I don’t have to do a whole EASI [Eczema Area and Severity Index] score. I can ask them about their itch, do an overall IGA, or investigator’s global assessment. I’ve learned that itch is very important for my psoriasis patients. So now I try to ask my patients [about it]; not [that] everybody itches, but a significant number of psoriasis patients do itch. But I haven’t always asked my seborrheic dermatitis patients about their itching. I think that we could all kind of take that back, and maybe that will make us even better in terms of understanding their burden and being able to monitor it a little bit closer.

 I think all of you said it best, but I would take it a step further and just make them unravel it and remind them of the itch, the dryness, the epidermal changes of scale, the redness, and then bring it back to why are we treating with all these different components of cleansing, moisturizing, and the active ingredient. But also make them think about the marathon and not the sprint, not just making [it] go away quickly, but making things stay away and the safety of giving them things that will do that.

 I think these are all such critical points. What I’m hearing from all of you, who are some of the best clinicians out there, is validating that they have a real medical condition and that they deserve appropriate therapy, that we hear them, we have new options that are available, we can help to simplify the treatment regimen, we can give them something that’s safe, effective, [and] well tolerated, and we can help them in this journey. My goal always is to make them not think about their skin. If they want to think about it in a good way, that’s great, if they’re happy with their skin, that’s great. I want you to live your life and your skin goes with you, but your skin should not be the center of how you live your life, trying to hide the flake, trying to hide the redness, trying to not scratch. I think this is really, really critical. I’ve learned a lot from my colleagues and from talking to each one of you. I think we have some really interesting information. I want to thank each of you for participating today, I’d like to thank the audience for joining us. I hope that you’ve all been able to take home some kernels of truth, and I’d like to thank you all for watching this HCPLive 

Transcript was AI-generated and edited for clarity. 

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Experts discuss the profound impact of seborrheic dermatitis on a patients' well-being, examining the common misconceptions and diagnostic delays.

Silently Struggling: Discussing the Unseen Burdens of SD

 I think what we’re understanding is, this is a condition that is highly prevalent. It is symptomatic, it’s itchy, it can be painful. It’s emotionally devastating because people are judged. And we wonder if our patients are paranoid because they say, I’m not getting the promotion that I want. I was not picked to be the one to present. But the truth is, we’ve seen studies where people are being judged based on their skin conditions. And you mentioned earlier this Harris study. This did involve a lot of seborrheic dermatitis patients. Do these patients know that they have a skin disease, or do they think that they just have a little dandruff and that this is not something that deserves medical treatment?

 Great question, Linda. I think one of the challenges is that there’s very little out there on education for seborrheic dermatitis. So many patients don’t actually realize this is a medical condition that could be potentially treated. They look it up online, to Neal’s point, they’re like, “Is this psoriasis? Is this eczema?” And they realize that seborrheic dermatitis can actually affect areas outside of the scalp. A lot of these patients, they do feel embarrassed, but they also feel like sometimes maybe it’s not serious enough to bring up to a health care provider, even though that Harris poll data showed it has such a profound impact on quality of life. So it’s a tough situation to be in.

 And I think as dermatologists, we don’t necessarily understand the journey that these patients have gone through. They ask dermatologists, well, how long do you think it takes for the diagnosis to be made? And they estimate maybe a year and a half or so. And then, as you mentioned, you ask the patients, and they say it takes between 3 and 4 years to make that diagnosis. In the meantime, these people are walking around without the care that they need. I think we really [owe] it to our patients to ask them a little bit more about their journey and what they’re going through.

 I think part of that equation, too, is the perception. Again, we talked before about [how] they just think it’s dry skin. They think it’s bad hygiene. They blow it off to things that they can correct at home. But I think the other population that deserves that, again, we mentioned before about the neurological patients, the HIV and the AIDS patients, they don’t realize that’s a significant part of their disease. And I don’t think they’re getting the treatment that they probably should be getting because I don’t think it’s identified as serious enough.

 Yes, many patients think that it’s a hygiene problem. I’ve heard parents say about the children, we just can’t get them to wash his hair enough or we can’t get them to use the shampoo that I put there for them. And so there are a lot of misconceptions here. And I think also some patients feel like they should be able to go to their local pharmacy and treat themselves. The failure of recognition of its medical condition or that a dermatologist can be so impactful in getting them better, it’s just not part of the everyday regimen that we see. So our outreach has to be better.

 I agree. I have seen so many teenage patients who come in. When you have seborrheic dermatitis, no matter what you do, I think your hair looks dirty because it’s flaky. You ask patients about hairstyles, and that impacts both men and women. I have one patient who’s actually grown his beard and his hair long and he said, I will kind of shave and trim it up once I don’t have this problem because by wearing the hair really long and keeping the beard, it covers a lot of the redness, the scaling and everything else. It’s embarrassing.

 Well, you wonder too how many physicians outside of dermatology are just also sending that message to them, saying, “Well, that’s just dry skin. It’ll go away. Shower once a day, shower twice a day.” So some of it’s not just on the dermatologist and the patient. I mean, there’s probably some disconnect somewhere where people aren’t getting treated.

 And I think education is so important, because unfortunately, if you shower 2 or 3 times a day, you’re going to end up having a worse problem. You’re not going to make the seborrheic dermatitis any better. It’s going to be really, really a significant problem. So I think what we’ve identified here is the fact that this is a major problem. I tell people, I could walk out into the waiting room today and find people with seborrheic dermatitis. You are not alone. It’s so common. And, unfortunately, I think this is something that our patients cannot necessarily handle on their own. For those with the most mild [cases], I think it’s appropriate, certainly, to try an over-the-counter product, try a medicated shampoo, see how it does. But I think what we’ve learned from the polls and our patients and actually doing these trials is that this is very prevalent. We’re not diagnosing it when it’s there in front of us, necessarily, if we’re not looking for it and the patient’s not complaining about it. And the patient doesn’t necessarily think about telling us about it. So there’s a lot going on. I’m glad we have a new option. It sounds like we don’t have a whole lot more on the horizon at this point, but fortunately we do have something that is safe and effective.

Transcript was AI-generated and edited for clarity.

Experts discuss the profound impact of seborrheic dermatitis on a patients' well-being, examining the common misconceptions, diagnostic delays, and societal judgments that hinder effective management and necessitate enhanced clinical outreach and patient education.

Dermatologists discuss the realm of emerging therapies for seborrheic dermatitis (SD), emphasizing the importance of breakthrough and failed trials.

Emerging Therapies in Seborrheic Dermatitis

 James, maybe you can talk to us a little bit. We talked about what’s new, and it’s exciting, but is this now the front door to a whole lot of other potential therapeutic options that are being investigated for seborrheic dermatitis?

 Yeah, it’s always really fun when we see just how much or how little we know about a disease or the pathogenesis, and then how they respond to a certain medication, [it] does give us some insights as to what’s actually causing it, right? So, it’s translational research, I guess you could call it. I think the fact that roflumilast foam works so well for seborrheic dermatitis tells you that PDE4 is absolutely a validated target as well as [able to improve] the skin barrier. We do have another PDE4, it’s a novel PDE4 topical that’s being studied, as well as a topical JAK [Janus kinase] inhibitor; this is more of an investigator-initiated trial. But what’s also interesting is that PDT, a photodynamic therapy study that’s being done for seborrheic dermatitis, and that comes off the heels of some positive data we saw with narrowband UVB and red light. I also think it’s worth mentioning negative studies, studies that didn’t pan out. There is an antimicrobial peptide that was used because we did see higher levels of [

] in some patients with seborrheic dermatitis, so it makes sense; let’s use an antimicrobial peptide that has antibacterial, antifungal effect. When they did a proof-of-concept study against ketoconazole and placebo, it just didn’t look all that much better than the placebo, so I think for now we can say that’s probably not the right approach.

 You bring up a really, really interesting point. We all run clinical trials, and I think that the dermatology community kind of takes it as a given, here’s a clinical trial, we run different studies, they meet their end point, we see a lovely delta of the active versus the vehicle, it’s highly statistically significant, yet as you mentioned, these trials don’t always pan out. You can have the best idea, as in this case, this last treatment, the best idea, it makes sense, it’s scientifically rigorous, it, we’re studying the right population, yet it might do well initially, and then when we bring it to those phase 3 clinical trials, it doesn’t work. And so, you have to realize this matters.

 And what it does is it helps us also understand what is driving pathogenesis. If you’re using a microbial modulating agent, and it’s not working, and then we know when you target the inflammation of these cytokines, it works, it kind of tells us what’s primary. So in seborrheic dermatitis, it’s not the microbial alterations, it’s the inflammation that’s primary.

 But you know, we could try to match the mechanisms of the drug to the disease, but if it’s not in the right vehicle, or if the trial end points are flawed, or if the study population don’t meet the criteria, but all of these other variables go back to the entire design of what made the trial not pass.

 And that’s so important, because when we talk about a topical, was the drug absorbed appropriately into the vehicle, does the drug penetrate into the skin in the vehicle where it’s supplied? There are so many different factors that go into it. And then again, tolerability. One should say it’s dissolving great and it gets into the skin, but can I tolerate it? Is it causing a contact dermatitis? Is it causing a problem? Is it causing my skin to dry out? Is it causing my hair to break? These are all those little pieces of the puzzle that kind of go together.

Dermatologists discuss the realm of emerging therapies for seborrheic dermatitis (SD), emphasizing the importance of both breakthrough and failed trials, while highlighting the need for scientific rigor and patient-reported outcomes.

Experts reflect on the transformative shift in seborrheic dermatitis treatment.

Optimizing and Expediting Care: A Novel Treatment for SD

 So, Neal, in terms of what we see with a new option, how does it compare with what we’ve had?

 The first thing is what we’ve had has been a lot of hodgepodge. It’s been throwing things at the disease and hoping it works. That’s the unfortunate part of it. I go back to 2008 when the first 510(k) came out. Even that as monotherapy had its shortcomings, unfortunately. But at the same time, incorporating a wash, incorporating a kind of moisturizer, those are separate from maybe just having a reliable once-a-day foam that we can use on all surface areas. When we have this available, this is the point where we say, “All right, take your next 10 patients and give it a try.” Because this way, if we get them out of the routine of azoles and higher-potency steroids, we can maximize their compliance and also not have to see them back as often.

 Now, I want to ask all of you, and just be honest. When a patient comes in, say they come in with toenail fungus, and they walk in and you see kind of moderate seborrheic dermatitis, in the past, do you bring it up? Do you bring it up yourself or is that something that you just kind of [wait on]?

 Sometimes I wait because in my mind, I’m like, “OK, what are we going to do? A little ketoconazole wash or maybe cream, maybe a topical calcium inhibitor, maybe a topical steroid. It’s going to take me 20 minutes to explain this. I don’t know how well it’s going to work. Is it even bothering him?” So, those are all the thoughts that are coming through.

 James, what do you think? I just came in, I have a full skin check. I have toenail fungus that I’m really obsessing over, but you look at me and you say, “Oh my gosh.”

 To your point, I’m always running behind. We have 3 or 4 other complaints that we’re trying to address, and we know that this is going to take another 5 minutes to talk about the 2 or 3 different topicals we’re going to prescribe. So, in the past, it was something that I wouldn’t proactively bring up, but I do think the results of that that quality-of-life study showing just how much it impacts people…was somewhat illuminating, that maybe I need to be asking to be a better doctor.

 And what about, Adelaide, in the pediatric world, do you bring it up or you don’t?

 We do bring it up. We try to give comprehensive care, and I also mentioned to the parent, is this bothering your child, or if the child is old enough to answer I can ask them. Sometimes the parent is far more worried than the child seems to be at the moment. The child may grow into a greater concern as they begin to have more advanced ages into the teenage years, but the 9-year-olds, usually they’re pretty oblivious, and that’s fine. We do offer it if they decide to just wait. I’m OK with that, but I always leave the door open. You can come back or, if you decide you want the medication, give me a call; we’ll fill out the paperwork [and] we’ll take care of that for you.

 I don’t buy that, because if you see patients scratching in the exam room you have to ask them, “OK, what’s going on up here?”

 So you will ask if I’m sitting here in your [office]. I just said I want a full skin check, I want to talk about my toenails, and I have a little hair loss, [but] you’re going bring it up absolutely.

 Absolutely. If they have seborrheic dermatitis on their face, I’ll go like this with my thumb I’ll say, “What’s going on here?”

 And that’s great, but Shawn, I’m going to come back to you now, before it was a conversation of, this is what you have, you have a condition, I can help you, but it’s going to be a conversation that’s going to take a little while, and I’m going to be able to help you in a very limited way. Does the option of having an effective and safe and well-tolerated drug now change it? Even though I’m squeezing you for time and I don’t want to let you out of the room, will you now maybe say, “Is that bothering you?”

 Absolutely, because we have good data behind it and it’s one agent and it’s one time daily. I think it’s an easy thing to tell a patient about. It’s easy for the patient to understand it doesn’t take long, so absolutely. I think we were waiting for this type of agent because it was complicated to explain the different options, and we honestly have no idea how those options even work. But now we have clear therapy that has great efficacy [and] it’s easy to give to patients.

 Yeah, and I agree. I think that we can provide better care, and as Neal and Adelaide mentioned, a more holistic approach to our patients because we’re given a gift. This is something that’s not going to consume our appointments.

 Absolutely. Even if you’re watching the clock and you’ve got people waiting, I’ll give them the sample and I’ll say, “Here, try this,” and I’ll go back to something else. Let them sit for 10 minutes and I’ll say, “OK, how did we do?” Because at least, for 1, that’s buying you a little time, but for 2, they’re trying the medication that you’re trying to give them, and then you know if there’s any tolerability issue on the spot.

Experts reflect on the transformative shift in seborrheic dermatitis treatment, offering effective and time-efficient solutions to identify the disease and educate patients about it.

Neal Bhatia, MD

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