Neal Jain, MD

This has been wonderful. Thank you so much for this rich and informative discussion. Before we finalize and conclude, maybe we can get some final thoughts on this whole discussion. Dr Feldman, would you start us off?

This is an exciting time. I’m probably the junior member of the team in terms of age. But I can see this drastic shift in our ability to treat what was a horribly impactful disease for all patients. We’ve been able to make so much progress, and there’s so much more progress to be made. These cutting-edge therapies that have just been approved—the large, lengthy pipeline for therapeutics—give us the ability to become more sophisticated in how we target these therapeutics to our patients. It’s a fun and exciting time.

Even in my short time in practice, I’ve seen leaps and bounds of improvement in how we can take care of these patients. I’m excited to have an option for these patients that I have confidence in.

I agree. We’ve come to this point where our understanding of biology has expanded dramatically. You can use a space analogy. We had little telescopes on the ground, but now we’ve got these amazing telescopes. That gives us this insight about what’s happening in our individual patients, and the ability to target therapies with what’s happening biologically is just amazing. Taking that a step further in the next decade is going to be exciting. Our patients will benefit and we’ll benefit from not only being able to nerd out about the science but also seeing the joy and the improvement from that scientific advancement.

There are some pearls that I’ll leave my colleagues with in terms of how I think about atopic dermatitis and how I manage atopic dermatitis. One is: don’t forget to ask what the movie looks like. It’s easy to walk into the room and think you can label someone’s severity. With some diseases, that’s true. With atopic dermatitis, it could have been really bad yesterday but really good today. These are the patients who pull out their phones and say, “Let me show you pictures of my skin.” We’ve all had that happen because they want to show you when it’s at its worst and not necessarily what they’re seeing today, which almost always turns out to be the best day of their year when they’re in the doctor’s office. Don’t forget to ask what the movie looks like.

Another thing, especially for my dermatology colleagues, is don’t forget to assess for their comorbidities, especially asthma. Just like psoriasis and psoriatic arthritis, you have to ask about their arthritis, or they won’t tell you. They also won’t tell you about their asthma unless you ask about it. You can really affect someone’s quality of life, for not just their atopic dermatitis but also their asthma, if you simultaneously assess for both. These are some things to keep in mind as you’re working your way through visits.

Another thing that’s really important and helpful when you’re seeing patients with atopic dermatitis is that these labor-of-love visits tend to slow you down in a busy clinic. Sometimes it’s hard to get the history efficiently from the patient, and there’s a lot of talking that usually has to happen during these visits. It’s great to have some analogies as you walk into the room to have in your mind so that the patient can still get the information they need without killing your whole day and taking up all your time in clinic. The analogy I like to remember is the military example. The immune system is like the military. You have different parts of the military, and 1 part is getting it wrong. If you don’t want to remember the full analogy, just remember to tell the patient the way the medicine works is it jams the radio signals of the allergic cells. That’s how it works.

If you have some of these things at your fingertips, it can make you more efficient and turn these labor-of-love visits into some of the most gratifying visits because you can really impact someone’s quality of life. Almost like no other disease that we see in our specialties, atopic dermatitis is 1 of the highest-impact quality-of-life diseases that we see in dermatology or in allergy immunology. It’s way ahead of things like asthma and other unrelated diseases that you would think would be more impactful. The itching of their skin and their rash is so impactful on their quality of life.

Thank you, everybody, so much for joining us, and thank you all for watching this 

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Closing out their discussion on the management of atopic dermatitis, expert panelists share clinical pearls and key takeaways from their discussion. 

Key Takeaways on the Optimal Management of Atopic Dermatitis 

The last piece is about education. This is important because to make a good shared decision-making process with the patient, they have to be on the same page. There’s a huge amount of education that has to happen. Of course, we all have luxurious amounts of time. You guys usually have, what, 1 to 2 hours for a new visit? Maybe longer—it’s only a few patients a day. No. We’re crunched. You have crunched time, and you have so much to cover. Sometimes the visit has many factors: where have you been? What are you using currently? What are your hopes, your fears, concerns? Then you get derailed. All they want to talk about is food. What food should we avoid? If we mention that, it can derail the whole visit. You’re trying to get to the next step to figure out how to get their skin better, and they’re doing this.

That doesn’t take into account the paperwork that has to happen after: the insurance forms, the prior authorization, the patient support stuff—all these things. How do we do that? One thing that’s so important is to bring external resources. I’m obsessed with handouts. I’m the king of handouts. Every time I see anybody for anything, they’re going home with a handout, and it’s usually going to list my action plan: what to do when you’re flaring up and what to do when you’re better. That’s such a big deal for me because it’s cut a lot of calls. Not 100%, but many calls [are answering the questions], “Which do I do first? Do I put this 1 on and then this 1?” I put them in numeric order. “In the morning, you’re going to do 1, 2, and 3.” We can really bring them through that.

The other piece that’s important is utilizing some of the national organizations that have patient support resources. I’m very conflicted because I’m a board member of the National Eczema Association. I don’t get paid any money. In fact, I donate a lot every year. I love the National Eczema Association. They’re a nonprofit organization that does a lot of patient advocacy support and education. I try to have my patients go to their website , to get signed up, to learn a little more about it. It’s nice when it doesn’t have to come directly from us. Sometimes they have a rapport with us, they understand us, but it’s nice to hear someone else’s voice, to get another opinion. That can help and give them some of the tools that can help them ask the good questions at the next visit, because I don’t like to be pushy. 

On the first visit, sometimes I say, “Here are some options. I want you to think about this. Here’s some homework for you to read. Let’s talk, either by phone”—if they’re from out of state or from far away—“or when I see you in a few weeks, we’ll make our decisions at that point.” How do you guys feel about the education burden that we have?

I agree. All of our patients are—if they haven’t already before they come to the visit—going to Google and Facebook to crowdsource and ask for advice from trusted friends and family members beyond their trusted allergist or dermatologist. Beyond the sheet that has all those important, point-by-point instructions, there needs to be a trusted links list. Something like the [National] Eczema Association and our national societies, which have great patient handouts. Let them kind of go down the rabbit hole online in a safe place, in a place they’re going to get good information.

Giving links and trusted sources are really helpful. But I also find that having that patient back with a short turnaround time is important. We’re all busy, but in patients with atopic dermatitis, we give them homework, we give them food for thought, but they need to come back shortly thereafter with questions fresh in mind. [Once they’re] able to move the ball along the field, get closer to that touchdown, get closer to that goal line, we can make management decisions incrementally. It’s OK to make management decisions incrementally for these patients. If you do that, they’ll follow you along that pathway.

I was going to make 1 quick [point]. We’ve alluded to the food thing. There may be some listeners [wondering], “Why are they laughing about the food? Why aren’t they talking about that?” I can speak a little for Dr Jain because I just attended 1 of his amazing lectures about food allergy and atopic dermatitis. The point—and the way I say it to my patients—is that I wish the food were the cause. When food is the cause, it’s easy. Arguably, you don’t actually have atopic dermatitis. You have an eczematous food reaction—you’re done, you don’t need us, you don’t need any of this. But for many patients, food may be playing some role. It might be inflammatory. They may have some food triggers. Of course, there’s a huge concurrence of real food allergies that are IgE mediated.

It’s a complex, messy thing, but it’s often not where the money is to get the skin better. There’s this tension because the patients want to focus on the diet, “How can I fix my diet to get better?” [We say], “I don’t know.” Even if you did a super-severe, extreme diet—we’ve all had patients with literal malnutrition because they’ve been so stringent on their diet, and their eczema is still terrible. It’s trying to redirect, not because we’re trying to push drugs on somebody, but because we’re trying to help them. Some of the patients and families have done this for years. I’ll just sit there and say, “You would’ve found it without me. You’ve cut everything out. You’re feeding the child rocks and water, but his eczema is still bad. I don’t think it’s food. I want it to be too, but can we work on other things?”

One of the little tools in my toolbox that I’ll share—this is a pretty universal thing; we all feel the pain of this is that I often say to families who are fixated on it, “When the skin is super inflamed, like now, when it’s a mess, it’s similar to when you get up on the wrong side of the bed.” You’re in a bad mood. No matter what anybody says to you, you’re going, “Grr.” Somebody says, “Good morning,” and you’re, “Grr.” But when you get up and you’re in a good mood, even if someone says, “You’re a jerk,” you say, “Have a great day.” It rolls off you.

It’s very difficult to evaluate what’s triggering your skin when it’s a mess, so I say, “Let’s get it better.” Let’s spend a little time cleaning things up. If there are still triggers, we can then see with much clearer eyes If they had an aha moment when they ate—fill in the blanks—dairy, gluten, strawberries, whatever it may be. That definitely made it worse. But right now, we can’t even see that. I put that there not because we don’t take it seriously. We do, but it could take up all the time. Sometimes that’s all people want to talk about. We have to redirect, because I want to get people better. Do you guys agree with that? Not to derail it too much, but it’s so important.

Absolutely. When we talk about what works and what helps patients get buy-in, we take for granted that we understand this pathology of atopic dermatitis, but they don’t. You just spoke about this with regard to their focus on foods or other things, what mindset they come in with. We need to take a step back and teach them that this is a disease where there’s barrier dysfunction, helping them understand that we’re learning that this is true not only of atopic dermatitis but also other type 2 inflammatory diseases, whether it’s asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, eosinophilic esophagitis.

We know that there are these similarities with this barrier dysfunction, and that barrier dysfunction leads to this inflammation. That’s how you develop food allergies. It happens first there. We need to help them understand this so that they get the focus away from some things that they have preconceptions about, and then we can educate them about the options to manage that and help restore that function to help their skin better. That’s hugely helpful. When this comes from reputable sources like the National Eczema Association, the AAD [American Academy of Dermatology], our societies in allergy, getting that same message repeatedly helps.

We did some survey on patients’ perceptions about bathing. You hear these patients coming in, saying that they’ve been told 15 things about what they should do with bathing, and they’re just confused. So to have some science to back this up gives us credibility, and that allows for the buy-in that ultimately leads to success in skin improvement.

Educating patients about their disease course is very important at the outset. It’s important to set expectations, and there’s no more important way for me to do that than to tell them this is not something you’re doing. It’s not your fault. It’s a genetic skin condition, and it’s a condition that waxes and wanes over time. There are going to be periods when you forget that you have eczema. There are going to be periods when it’s very flared. Our job is to control those flares so that you’re not having flares very often and when you do have flares, to not be concerned about treating them at the first sign of trouble.

One way to do that is to talk about the use of steroids and how to properly use them so that they’re not afraid to use them. Another way is to use nonsteroidal medications that might promote less fear within the patient or the parents so that they use them at the first sign of trouble. I always say that it’s like a little fire that’s burning. The sooner you put it out, the better off you’ll be—but you have to completely put it out. If you use your medication for a few days and then there are still some embers there, it will come right back. It’s important to set those expectations.

A third thing that’s very important to talk about is avoiding systemic steroids. Very commonly, patients come to the office with chronic waxing-and-waning flares. It’s a vicious cycle, and it’s usually triggered by the use of systemic steroids, either injectable or oral prednisone or Medrol dose packs. What happens is the patient’s skin rebounds once they come off their systemic steroids. It’s important to educate parents, patients, and providers that using systemic steroids should be a bridge to some other therapy and should not in and of itself be the plan to treat someone’s atopic dermatitis. In the long term, they have adverse effects. In the short term, they’re going to create a rebound that’s only going to continue their waxing-and-waning flare cycle.

Shared insight on the best ways to educate patients on their atopic dermatitis and explain the nuances of available therapies.

Educating Patients on Atopic Dermatitis and Inflammation 

We have so many new treatments, so many new tools in our toolbox. Could there be any unmet needs left? I think there are, we still do have some unmet needs, and I’d love to talk about that now with you. When we think about atopic dermatitis in 2022, where do we have gaps in therapy or gaps in knowledge? What are you thinking about as the next big things to tackle?

I think what you said, Dr Lio, toward the conclusion of our last section, about personalized medicine, we can try to use that patient in front of us as a living, breathing biomarker endotype, and try to surmise, based on their comorbidities or lack thereof, their prior response to therapies or lack thereof, what pathways are dominant in their disease state. But if we could somehow get their expression signature, what truly is overactive in their skin lesions, in their bodies, systemically, because as we know, this is not just an external-to-internal type of disease state. We’re talking about an inflammatory, internal-to-external disease state.

Can we get that heat map analysis on a patient-to-patient basis and block the right pathways in the most targeted way we can with the most efficacy and the least amount of potential unintended adverse effects? That would be the magic bullet, in my opinion. And I think we’re actually closer to that than we would think. I don’t think that’s pure science fiction at this point.

You make a great point. You think about the old 

 episodes where, they just did a little scan up and down, and right there you’d have your answer, and you just give them their injection or whatever it might be. But I agree, I don’t think we’re that far, with tape [stripping] studies, etc, being able to gene-chip and say, “Well, what’s overexpressed? What might be the right therapy?”

I think additional challenges that we certainly continue to have to deal with are evaluating our patients with skin of color, and with different racial and ethnic backgrounds. There’s still a lot of confusion and a lot of training that needs to be done. And unfortunately, these patients are often underrepresented in some of the studies that are performed, for a variety of reasons. Will we see similar therapeutic effects and benefits in these individuals? Are we really assessing and offering them access to these therapies in a way that’s meaningful to them?

Can we intervene early, and are these therapies all appropriate for younger children and our pediatric populations? And if we do intervene, can we have that disease-modifying effect? I think that’s an area that needs to be explored, and hopefully, our colleagues in the industry will hear that call and heed that call. so we do get the data to hopefully, again, impact the long-term outcomes of these patients.

I think there are significant unmet needs in the world of atopic dermatitis. I think understanding that this is a genetic condition, the holy grail would be modifying that genetic condition in some way, fixing the genes that create the skin proteins, like filaggrin, that are abnormal, which drives this process.

Another unmet need is intervening early. We don’t know yet, if we intervene by initiating systemic therapies in younger children who are showing atopic predilection, can we actually alter their disease course, so that they’re not going on to have adult forms of atopic dermatitis? We do have evidence that starting early allergy immunotherapy in these patients can alter their disease course, but we don’t yet know if we use some of these newer systemic agents to treat atopic dermatitis, does that augment their disease so that they don’t go on to have lifelong asthma?

Then within the treatment paradigm itself, we do have some unmet needs. Ideally, we would like to not have to give people shots if we can avoid it. We would like to dose people who are on oral therapies less frequently. We’d like to have therapies with improved safety and efficacy profiles wherever possible, and we want to get indications as young as possible because our youngest patients are some of the most severely affected by atopic dermatitis.

In the next 10 years or so, I hope we’ll continue to advance the therapeutics in atopic dermatitis and be able to fine-tune the systemic options that are the best for the patient.

I love the idea that, when we think about precision treatments, we often just say it’s the treatment that’s going to help the best in terms of their defect and get them better. But you brought it up, Dr Feldman, you said it. I think it’s so important, that it’s also going to be the safest treatment for them because precision medicine is not just about the best response, it’s about the safest drug too, and so we’re going to think about both sides of this, which is great.

The other piece, I think is, and I’m definitely not somebody who is afraid to spend health care dollars. I have sick patients who are complicated, and so I use expensive treatments all the time. But I’m still sensitive to it and sympathetic to the fact that not everybody has health insurance, not everybody has good health insurance. And sometimes even a number that we throw away, “It’s just a $30 moisturizer,” for some people, that’s the difference between making the rent that month. So I really want to see, how do we get more affordable care to people as well, because I think that’s a huge unmet need.

I get all these patients who are stuck, and sometimes especially if they’re on a government form of insurance and assistance, they can’t get the rebates and all the little freebies that we can use for other insured patients. I find that to be a huge problem that we also need to circumvent.

A broad look at the ongoing challenges and unmet needs in the field of atopic dermatitis management.

Unmet Needs in the Management of Atopic Dermatitis 

One of the most common questions I get from my colleagues when I speak about atopic dermatitis is [about] diagnosing and managing difficult cases. I think the first point to be made is that people with dermatitis are a very heterogeneous group, and atopic dermatitis within dermatitis is also a very heterogeneous group, where every patient presents a little differently.

I always say I care much more that you know you’re in the pathway of dermatitis than I care that you can fit it in the classic textbook description of atopic dermatitis because the description of atopic dermatitis is just that—it’s a clinical description. It’s not necessarily based on the immunology or pathophysiology of what’s going on, on a more microscopic level of the skin. If you know you’re in the dermatitis pathway, to me that is more important than being able to subcategorize the dermatitis.

I think it’s important to look for confounding factors, like allergic contact, or just complete mimics of their disease. I’ve seen scabies missed as atopic dermatitis. I’ve seen CTCL [cutaneous T-cell lymphoma] missed as atopic dermatitis; allergic contact, certainly, and various other inflammatory diseases. There’s a notorious diagnosis in the world of dermatology called psoriasiform dermatitis, where you can’t tell if it’s psoriasis or atopic dermatitis, so then you biopsy it and then the biopsy comes back psoriasiform dermatitis. Basically, the pathologist is telling you that they can’t really tell either under the microscope.

One pearl when I see patients like this, I try to use the history to help me. Do they have a history of other atopic conditions? But also, sometimes I’ll do what I call a diagnostic therapeutic trial, where if I think it’s dermatitis, and let’s say they have some background asthma as well, for example, I will treat them and block that pathway with something like dupilumab, and then reassess them at 12 weeks or 16 weeks and see how we did. If we made no improvement at all, then I think maybe we’re in the other pathway. If they cleared nicely, then I’m confident in saying that by blocking that pathway, I treated their dermatitis.

I think in the future, we may categorize these things more by the immunology that’s happening in the skin as opposed to a clinical description of what you’re seeing visually. But I think using some of the histories to help you and some of, not just what worked to treat them, but almost as importantly, what doesn’t work to treat them, can help you when you’re trying to discern some of these more difficult cases.

Marc Serota, MD, elucidates the heterogeneity of atopic dermatitis and explains how this can contribute to challenges in treating patients.

Neal Jain, MD

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