Personalizing Treatment Selection in Atopic Dermatitis - Episode 6
Peter A. Lio, MD, shares his approach to presenting treatment alternatives to patients who want to stop using long-term steroids for treatment of AD.
Raj Chovatiya, MD, PhD: To round out the case, I might revisit our patient and go back to you, Dr Lio. You have somebody like this who has many of these cutaneous issues and has not necessarily been taught appropriately how to use a topical steroid. They have atrophy and striae, thinning, and visible vasculature, and maybe even dyspigmentation. What are you thinking about next when it comes to, let’s say, topical therapy.
Peter A. Lio, MD: Yes, I’m always telling my patients that we have these 3 great hurdles. First, we’ve got to get you clear. Second, we’ve got to keep you clear safely. And then third, you have to be able to keep it up. And a patient like this, maybe they’re able to stay clear, but not safely. We’re getting all of these adverse effects, and of course, there is the perception of adverse effects and patients are worried about them, but then there are real ones. And these are real examples of stuff that’s bad and we don’t want to push this any further. Some of it may be reversible, and some of it may not be.
That being said, it doesn’t necessarily mean that we have to abandon all therapy. Some of my patients come in and they’re so skeptical, they’re like, “I just want to go as natural as possible, I don’t want to do anything.” We’ll hear about these ideas of topical corticosteroid withdrawal, where people want to stop all medications, or moisturizer withdrawal treatment, all these things. So, I say, “No, we don’t necessarily have to just suffer, because that would be terrible.” But we can do other things. Topically, of course, we have several nonsteroidal agents: our tacrolimus, pimecrolimus, our topical ruxolitinib, and our crisaborole, with a whole bunch of new things in the pipeline. Two are approved for psoriasis, but I think are pursuing indications for atopic dermatitis, and that’s tapinarof and roflumilast. I’m interested in both of these, and some other ones coming. So, we potentially could do some topical things.
Of course, we can go back to basics, as Dr Hebert pointed out, what about great bathing? Gentle products for moisturizing, are we doing enough of that? If they’re really severe, can we use wet wrap therapy? Sometimes, again, even with just moisturization. So, thinking about it holistically and putting them together. But of course, having a low threshold to say, what about the next steps? Should we jump to a biologic? Should we use something that is systemic to help from the inside out?
Raj Chovatiya, MD, PhD: I think that’s been one of the most exciting things about reinvestment in the topical space, particularly with all the hurdles that you rightly point out. If people are doing really well with their topical therapy, it’s just a matter of trying to fine-tune that balance of what they’re getting out of it vs what they’re experiencing with it. They are definitely a good direction to go, and in the case of, just for the sake of discussion, topical ruxolitinib, a lot of strong data show the majority of patients in the course of the trials hitting end points of itch, hitting end points in clearing. Even the phase 2 trial is seeing efficacy compared to something like triamcinolone, looking even better than that as well. It is giving us this idea that perhaps now we have the flexibility, even beyond some of the previous options, where efficacy may have been a little more limited, to step that up in body locations where traditionally we were going to have issues with potency when it comes to a topical corticosteroid.
Transcript edited for clarity