Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 13
Considerations regarding how to best select from and use newer therapies for atopic dermatitis.
Melodie Young, MSN, RN, ANP-C: Douglas, when you’re speaking about the medications and therapies that are coming down the pipeline, we have some experience already with JAK inhibitors and monoclonal antibodies, and we have some preconceived concerns as clinicians about [adverse] effect profiles. But for patients, they’re also going to be looking at things as simple as injectables, some are going to be oral medications, which is going to be new to have drugs developed for atopic dermatitis that are oral agents, and then also some new topical agents. Do you think this is going to be a major addition to have this multitude of different ways to go about and approach it? Or do you think we’re going to be looking at these different pathways for helping patients?
Douglas DiRuggiero, DMSc, PA-C: This is incredible to see a renaissance of so many new therapies coming into this particular disease state. I’m excited. It’s nice to have options, not just in the target site that we are talking about; it’s nice to have options for our patients, for oral versus topical versus injectable, and how to combine them. The big issue for us is that we’re never going to want to put a patient on something that has good efficacy but has very poor safety. We talked about the comorbidities with atopic dermatitis, whether that’s already having conjunctivitis or having some depression, anxiety, or having allergies, or asthma. The last thing we want to do is create a new comorbidity through putting them on a medication. As these new products roll out and whatever delivery form they are, the new issue will be us taking a close look as we get our hands on the information, as information is made more public, and as the indication and the launches of these medicines come, to see are we going to put our patients on it and how do we counsel them on things to look out for?
Melodie Young, MSN, RN, ANP-C: Some of the medications are going to have recommended some laboratory monitoring that’s going to be associated with them. Susan, with your experience, do you feel like having new oral agents will be a game-changer, even if they have different [adverse] effect profiles? Do you think patients are looking for oral agents? Or do you think the route of administration is not as key of a component with decision-making for patients?
Susan Tofte, DNP, MS, FNP-C: I do you think that some patients would defer to taking a pill over giving themselves an injection. Some patients are always going to be a little averse to giving themselves an injection even if you explain that it’s like a diabetic has to give their insulin shot every day. Having a new treatment and a new delivery of these treatments is going to be a good thing. The JAK inhibitors are exciting on the landscape and the clinical trials going on, but they’re not without [adverse] effects. I think they’ll be competitors for dupilumab, but I think their safety profile is going to probably make some patients pause to think about whether they want to go that direction. I don’t know a lot about the JAK inhibitors, but I know that GI [gastrointestinal] [adverse] effects are common and could be problematic. We want to offer our patients multiple options if we can, and handpick the one that we think is going to correlate best with their disease and their success in maintaining control of their disease. It will be good to have choices, but by weighing out all the benefits and risks for each individual patient.
Melodie Young, MSN, RN, ANP-C: Do you feel like the medications you use now, for example, dupilumab, is it usually a monotherapy? Or do you usually have to have some additional treatments, either continuing the over-the-counter therapies or some other topical medications? Do you think that’s acceptable to patients and clinicians, or are we wanting just 1 thing to be the only thing that’s going to be required for treating?
Susan Tofte, DNP, MS, FNP-C: I would say that my patients who are on dupilumab also have topical steroids. They’re not necessarily needing them or using them, but if they have 1 little spot that’s persistent, it’s nice to have the topical steroids to maybe treat that 1 spot. It’s the same thing with patients with psoriasis on biologics; sometimes they’ll have 1 spot that just won’t go away. I think having the topical steroids as a backup, my patients are totally fine, and I’m fine with them using it that way as well.
Keri Holyoak, PA-C, MPH: I would agree with Susan. Most of my patients are not on monotherapy, we layer the therapies. It’s good to give patients that extra little umph. I think we’ll continue to layer them and use them in combination. A monotherapy sounds amazing. Wouldn’t that be great? Time will tell. I think we’ll use these new therapies and we’ll embrace them.
Douglas DiRuggiero, DMSc, PA-C: Any patient who has had atopic dermatitis for any length of time and has already been on topicals will never not want it. It’s like a safety blanket; they want to snuggle up to that tube of cream and put it under their pillow. They can come in and be 100% clear for 6 months in a row on dupilumab, not even a little, dry patch anywhere. On the way out the door, they’ll say, “Hey, can you give me a refill of that triamcinolone? I noticed that mine’s expired,” and they don’t have anything. “I just want to have it in case.” They want to have something whether or not we want them to be on something. It’s good for them to be on something, whether it’s a calcineurin inhibitor or one of the PDE4 creams. I tell my patients that these medications may not keep you 100% clear 100% of the time, but I anticipate that they will keep you almost all the way clear almost all of the time. That’s a slightly different expectation to say almost all the time. I think they jive with that and because of that, I say, “I don’t mind giving you a topical steroid cream to use but realize, be cautious with it and where you’re doing it. If you find that you’re having to use it consistently, that’s a reason to come back and see me ahead of your follow-up because we need to re-evaluate this therapy if it’s really starting to fail.”
Melodie Young, MSN, RN, ANP-C: A lot of my patients want to have mupirocin on hand because they were used to having superimposed bacterial infections, and they remember how that could be a trigger. I think there are other factors, like seasonal changes. When people go to the mountains, or in the dry climates, they’ll notice there are changes to their skin. My simple illustration is the sawtooth, the up and down of the disease. There’s much more of a foundational approach to taking the disease from a moderate or severe patient to a disease that is manageable by trigger avoidance and with a bit of topical therapy, it makes it almost mild. Sometimes, they don’t need to do anything else.
Douglas DiRuggiero, DMSc, PA-C: They’re still moisturizing; the moisturizing doesn’t go away. There are recommendations to put a moisturizer on once or twice a day every day. It has to be there; we have to keep that barrier intact. That never goes away. I don’t want anyone to have that impression; we’re talking about prescription topicals that we hope to move away from, but not the moisturization and the bathing techniques and all those kinds of things.
Keri Holyoak, PA-C, MPH: It’s eliminating those irritants too. So many times, my patients will come in and say, “Yeah, I’ve eliminated it all, but I burn just a few candles.” It goes back to education.
Melodie Young, MSN, RN, ANP-C: With the things they want to do, we tell them these are not cures, these are treatments, and you have to continue what you were doing before.
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Transcript Edited for Clarity