Advances in the Management of Atopic Dermatitis - Episode 16

Atopic Dermatitis: An Evolving Treatment Landscape

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Closing out its discussion on atopic dermatitis, the panel considers best practices and unmet needs in the treatment landscape.


Lawrence Eichenfield, MD: Leon, how do you anticipate the treatment landscape evolving with JAK inhibitors and in addition to JAK inhibitors?

Leon Kircik, MD: Let me first go over the topical JAK inhibitors. They will really change the landscape. I can’t remember who it was, but somebody said they will probably be really useful for maintenance treatment. I agree with that, because we want to prevent the disease from coming. We have more or less good tools to get rid of the flares. Now we have dupilumab. We have topical steroids; they work really well for a week or two. The problem is we want to make the next flare as far away as possible and decrease the number of the flares. How do we get that? How do we maintain that clearance? Topical JAK inhibitors can be a great tool to do that. That’s one.

Two was brought up by Lisa. With the oral JAK inhibitors, the main use will be just for flares, right? If dupilumab doesn’t work or if something else doesn’t work, why not have another agent, that very short targeted treatment, for a couple of weeks—4 weeks, 8 weeks, whatever the period is—just to get that flare over and avoid the long-term safety issues without worrying about it. Also, they’re orals. Nobody wants a shot, but people use it because they have no other choice. Now we’ll have another choice.

Lawrence Eichenfield, MD: Peter, did you want to weigh in on the treatment landscape? Do you think we’re going to get more patients, or do you think we’ve seen them all? Do you see this as continued evolution and better care?

Peter Lio, MD: I do hope and think we’ll see this expanding out to a lot of the people who have given up on the medical system. I meet some patients who are coming out of the woodwork because they’ve gotten the same diagnosis and treatment regimen, something like a big 1-lb jar of triamcinolone with 11 refills and were told, “Good luck.” But now they’re understanding we have new insight into the disease and new treatments. I’m seeing more patients. And we know if the numbers are correct, we’ve only seen a drop in the bucket of all these patients who are moderate, severe, and uncontrolled. Our treat-to-target keeps getting better and better. Just like what we saw with psoriasis where we used to accept, “That’s pretty good on methotrexate, you’re hanging in there,” now we’re aiming for clear or almost clear for these patients. The same is happening to atopic dermatitis. I’m excited.

Lawrence Eichenfield, MD: That’s great. Peter, I’m going to stay with you because you’re such an important figure in educating practitioners about atopic dermatitis. You’ve been very influential. With this changing and dynamic aspect of therapeutics, what are your recommendations for primary care practitioners [PCP] on best practices for collaborating on care and patient selection for referral?

Peter Lio, MD: If I could get everybody to write out an eczema action plan, that would do 90% of the work. It’s a pain in the neck. It’s a lot of work. It takes some coordination. It takes a few extra moments, but even if it’s just some scribbles, just to give the patient a sense of where they’re going, it’s is an incredibly powerful tool that can be integrated into anybody’s practice. If you do it in a digital template, you can also copy and paste it into your notes. Now you know exactly what you told the patient. You print it for the patient so they have exactly what you’ve recommended in the order of operation, when they’re flaring up, when they’re better. It’s such an elegant thing.

As Lisa pointed out, we have those great hurdles. “Can I get you clear? Can I keep you clear safely, and can you keep it up?” Any time a patient can’t jump over one of those hurdles, that’s absolutely a reason to refer. And frankly, that applies to me, too. I have really tough patients where I’m not sure and I say, “I want another opinion. We can’t get you better, so let’s get someone else involved.” There’s no shame in that. I always try to remind our PCP colleagues that dermatologists do a fair amount of primary care medicine, so there’s no stupid consult. There’s nothing that we think is dumb. People come in for skin screening all the time, so we’re very much used to people who just want to get a check over. And in that capacity, any patient who is referred by another provider who says, “Listen, I’m not sure what’s going on,” or “I’m not able to help them,” we want to help to try to get them better. We’re all part of the same team. Our goal is not to be right, it’s not to be famous, it’s to get the patients better.

Lawrence Eichenfield, MD: That’s great. I’ll add to that. It sounds silly to say, but there’s consciousness raising about the disease. Even as experts who deal with a lot of atopic dermatitis on a daily basis in our practices, I’m more cognizant of what the disease impact can be. That’s across the whole spectrum.

One of the things as part of messaging to primary care is, if you’re watching this, great. The point is to get educated about the disease and recognize it. Change the messaging. For pediatricians, I talk about the asthma model because they understand an asthma model. It’s about long-term disease control and figuring out what medicines you need. And if you need someone beyond you to establish long-term disease control with minimal rash, minimal itch, and minimal sleep disturbance, then send them out. Certainly, I’m in the situation where, as Peter said, there are times it’s like, “I need an immunologist. Help me, please.”

Part of best practices is recognizing when the patients outstrip what you are able to bring to it. But also be alert to the changes that are going to happen in therapies because a lot of those are going to be incorporated into primary care practice, too, even though it may be specialists who are leading us toward that.

Let’s go to the last area of discussion on how we educate patients and their caregivers to keep them up to date on the management of atopic dermatitis. Does anyone else want to come into that, or should Peter go back to it? Peter, why don’t you lead us off on that? What’s your sense or your approach on keeping people up to date?

Peter Lio, MD: It’s hard, because even we are feeling a little of that drowning sensation with so many papers. I did this plot, I used one of the scholar sites and was able to show that the number of publications in atopic dermatitis in the past decade looks exponential, and I feel like it’s going to keep going up.

What are some things I think are helpful? Certainly things like this. These are great because you get to hear a lot. Even I learn a lot from these meetings, because you get to hear the digested form of a lot of primary data, a lot of exposure to papers, and the chance to talk to our colleagues. There are many online things like this.

Another great thing to do is use email digests for topics. I use one that’s actually from the Google search engine, and I have targeted certain things so it gives me little digests every day—or you could set it every week—and I think that’s a nice way to see the papers just to read the headlines or read an abstract. And then if you’re really interested, you can click in and learn a little more.

Of course, there are some innovative things. I’m excited to be working with a group that’s creating medical video games for education. They’ve packaged, somewhat like the Duolingo language learning website and app, it’s the same concept with CME [continuing medical education]-type activities for different specialties. I love this kind of innovative thing. And then finally, I really do think that reading journals is still important. Even though we somewhat let go of them, they’re still important and I still like to flip through my journals even physically when I can, even though that dates me.

Lawrence Eichenfield, MD: This was an incredible discussion, really capturing some of the breadth of the issues that we deal with in atopic dermatitis. I thank you all for your contributions to the discussion. It was so reflective of where we are. I hope you get a chance to do this together with such experts. I thank all of you for contributing both your knowledge and experience with patients, and the energy that you bring to this arena of atopic dermatitis as we work together to bring better care and hopefully less influence of the disease on the life of individuals.

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Transcript edited for clarity.