Collaborative Management of Atopic Dermatitis - Episode 3
Peter A. Lio, MD: The treatment approach to atopic dermatitis has changed dramatically in just the past few years. Excitingly, it’s about to change a whole lot more in the next couple of years as we get all these new entries into our therapeutic armamentarium. But the overall approach to treatment is pretty structured and solid. That is this concept of a therapeutic ladder, with steps going up as needed, and that first step, or first rung on the ladder, is a couple of things. No. 1, it’s good moisturizers. We think that moisturizing the skin helps protect it, helps keep the water where it belongs inside the skin, and also helps protect the skin from irritants, allergens, and pathogens. Moisturizing really seems to be a very inexpensive, very safe first step.
No. 2, avoidance of known triggers. If people know they have irritation or itching from certain fabrics, certain chemicals, from pets, for example, avoiding those things can really help prevent those flare-ups. We can start there. No. 3, gentle bathing. You don’t want people using harsh products that could irritate their skin and strip their oils.
If that’s not enough, then we can go to step 2, which is a reactive approach. For milder patients, this works fine. Maybe a mild corticosteroid, a topical steroid that we can use, maybe a nonsteroidal. We have a couple of different nonsteroidal agents. We have our calcineurin inhibitors, which are pimecrolimus and tacrolimus, and then we have a newer agent that was released just a few years ago called crisaborole. That’s a phosphodiesterase-4 inhibitor. Again, anti-inflammatory, nonsteroidal. We might be able to use those in a reactive way. Use this when you need it, and take a break when you don’t. For many patients that will be enough.
The next rung up are those patients who say, “I’ve used it, but it wasn’t enough.” Or more commonly they say, “I used it and I got better. But as soon as I stopped, it flared up. And you told me not to use the medicines all the time, particularly for topical corticosteroids.” We don’t want people using them for long periods of time without a break. It can damage the skin, it can thin the skin, and they can become dependent on them. We don’t want that to happen.
For those patients, we have to go up to the next rung, and that’s when we start thinking about things like systemic treatments. That includes things like phototherapy. We usually use narrow-band ultraviolet B in the United States. It works very well for a number of patients, although it can be difficult to get. The accesses is a problem. We might think about some of the conventional immunosuppressants off-label. Those are a little dangerous and have to be used by people who have a lot of experience: cyclosporin, azathioprine, mycophenolate, and methotrexate.
In 2017, we had a new entry, dupilumab. That is a first biologic for atopic dermatitis, not a steroid, not an immunosuppressant, a targeted anti-inflammatory treatment that blocks IL-4 and IL-13. That has changed the game because that actually is labeled for atopic dermatitis, moderate and severe. Then we’ve had it brought down a couple of age levels. It started out as 18 years and older, and now it is approved for ages 6 years and up. We have a lot more patients we can use this on who need it in our appropriate patients.
Making a shared decision with our patients is probably the single most important thing. Because I often joke with them that the cream is not going to help from the bottle. If you bring it home and don’t use it, it’s not going to help. Patients have to be onboard, and ideally excited and enthusiastic about their treatment approach for it to work best. A is to adhere to the regimen, and B, I truly do think that if they’re excited about it, chances are we’re going to harness that placebo effect. That therapeutic alliance feeling can get a better result in the end, which is my goal very selfishly. I want people better, that’s what I want. I will use any tool at my disposal.
Patients often do have very strong opinions. In particular, for me, I run an integrative eczema center, so many patients come in and have strong opinions about a lot of our treatments. In particular, topical steroids, which I will tell you, full disclosure: I like them a lot. I still use them a lot. They’re incredibly effective. They’re incredibly accessible because they’re inexpensive and widely available. Even though they have some legitimate and concerning risks, we also have a lot of experience to know how to use them quite safely.
That being said, some patients say, “I’m not using them. I’m only using the tiniest amount.” I’ve had to find ways to take their opinions, to take their preferences into consideration carefully. I have lots of little tools that can help me minimize those, or sometimes actually avoid them and replace them with other treatments.
That’s why, anytime a new treatment comes out, I’m quite happy because I need all the tools I can get, especially when patients don’t want to use some of the most important ones.
Transcript Edited for Clarity