Personalizing Treatment Selection in Atopic Dermatitis - Episode 5

Challenges Faced by Non-Dermatologists When Using Steroids

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Adelaide A. Hebert, MD, comments on the need for nondermatologist education on the basics of skin disease care.

Raj Chovatiya, MD, PhD: One of those issues is oftentimes patients will come in with topical corticosteroids. That can sometimes be prescribed by a general pediatrician, a general practitioner, or a primary care doctor. I’d like to go back to you, Dr Hebert. What role do you think the generalist who might see the patient before dermatology has, in terms of that topical corticosteroid plan for atopic dermatitis?

Adelaide A. Hebert, MD: I think many of our colleagues who are not dermatologists didn’t get adequate education on steroids, which ones are useful, which body parts to apply the steroid, and they maybe don’t label their prescriptions with the exactness that we do. We tell our patients at the University of Texas where on the body to apply the medicine. Now if the box gets thrown away and there’s no instruction on the tube, that remains an ongoing challenge. But we do provide education. We also tell them that the numbers behind the topical steroid have no indication of where I want them to use the steroid, and it’s not related to the strength. That’s very confusing. I say that’s just there to confuse the nondermatologists, and it works very well. I tell them to follow my guidance.

I think our colleagues outside of dermatology are not completely comfortable with the entirety of eczema care. I don’t even see foundational things such as bathing and moisturizing being very well addressed, and I don’t find that patients come in well-educated. I can say, there are many of us on this call who conduct clinical trials. And I know when patients come into the clinic who have not been seen by a dermatologist, we’re often surprised that these patients were not controlled even with the basics. So, I don’t think our colleagues treat them well.

Another big caution is the use of oral steroids. I’m not a particular fan of the use of oral steroids, but now that patients tend to go to primary care, urgent care centers, or use telemedicine, we see many patients who get oral steroids. Then when they rebound, they come into our offices. I think they’re much harder to control. But they’re also much harder to satisfy because of the quick onset, and the dramatic relief without real insight into the long-term adverse effects, or even the short-term adverse effects that have recently come to light. Dr Lio mentioned the use of topical steroids and the relation to adverse effects, even fractures or osteoporosis, but oral medications in the steroid class can certainly be associated with fractures, thromboembolism, and so forth. These are concerns. We have a long way to go in dermatology in educating our colleagues in the primary care arena on best practices for atopic dermatitis.

Raj Chovatiya, MD, PhD: Yes, you nicely explained this idea of what we should be thinking about for acute vs chronic measures. I think that’s the balance we want in dermatology, of how we do that safely. And given how much scrutiny and attention that’s been placed on boxed warnings and safety, people tend to forget that corticosteroids are the original medication for treating every possible thing that could go wrong with them, especially in a synthetic form right there in terms of our years of use.

Transcript edited for clarity