Personalizing Treatment Selection in Atopic Dermatitis - Episode 15
Experts in dermatology share general guidance for use of topicals, switching from topical to systemic treatment, and when combination therapy is an option for patients with atopic dermatitis.
Raj Chovatiya, MD, PhD: I want to focus in on topicals, given that clinical scenario I outlined. Let’s say you were going to stick with topicals for the in-between patient we talked about. Peter, is there general guidance in terms of body surface area when you’re thinking about topicals? A lot of this ties into earlier discussion on what’s practical for a patient, something they can follow through on. Is there a sweet spot where it works, beyond which it becomes impractical even if it’s mild or mild to moderate disease?
Peter A. Lio, MD: That’s another problem with the way we categorize disease. Frequently, if we’re doing something like an easy score, that takes body surface area heavily into account. But we have patients with very small body surface area, where it’s quite severe. Other times, patients are mild, but it’s overwhelming—like 90% body surface area. Part of the calculation is responsiveness to treatment and feasibility of treatment. For littler kids, you can get away with whole-body application of topicals. When they’re little, it’s easy because they’re portable; the parents can usually do it. But as the kids get older, adolescents in particular, it’s very tough. They get easy burnout and very fatigued about putting on a lot of topicals. For those patients, even small body surface areas might be an issue.
That’s the best way to approach it: on a person-to-person basis. But I always say that everybody’s got to try some topicals. Even when we’re on systemics, almost all our patients on the systemic agent are going to use some topicals; you’re never outside that. It depends on the response. Sometimes I’m confident that this is never going to work, and that when I talk to them next week, they’re going to say they’re worse. I think that they’re going to have to go on to a systemic agent. Then I call them, and they say, “No, it’s great. Pretty much everything is healed. I did most of the body for a few days, everything responded, and I’m focusing on my hands or my ankles. We made it.” Other times it’s small. I said, “Come on. Let’s push hard. We’ll do everything. We’ll do wet wraps.” Then in 2 weeks, they call me and say, “I’ve been using it like crazy, and my hands are still miserable and cracking and bleeding.” Then we have to go to systemics.
Raj Chovatiya, MD, PhD: Oftentimes, when we’re making that move on the value of step-wise therapy for atopic dermatitis, we’re adding many of those therapies together. It’s not a straightforward discussion of trading in your topical for a systemic. There’s often concurrent use. Matt, when is combination therapy viable for patients? And when do you want to see if monotherapy does its thing? Is there a difference between the 2, or are you doing everything at once and peeling off? Take me through how this works in your practice.
Matthew Zirwas, MD: For me—and we all practice this way—every patient who’s on a systemic is on combination therapy. Whenever I’m talking about drugs—let’s say I’m giving a promotional talk for a systemic—I tell the audience to ignore the monotherapy data, because they’re not clinically relevant. I tell them, “Those were data the FDA required, but they’re not clinically relevant.” The data we want to look at are the combination therapy along with topical corticosteroids. That’s what’s always done in the trials. When I put somebody on systemic therapy, I’m telling them, “Use your topical, but hopefully with the systemic that we have, you won’t need to use the topical anymore.” As you get better, you don’t need to keep using it.
That’s the case when I have people on combination therapy. If they need a little topical, I’m not worried about it. It’s not, “Let’s put you on a systemic. Once you’re better, we’ll stop the systemic and see if we can keep you on the topical.” No, it’s, “Let’s start you on a systemic. Assuming the systemic works good, you don’t need to use the topical anymore.” That’s the direction that I’m going in. Part of that is because it’s so hard from an insurance perspective to start and restart the systemics because patients stopped ordering it, or their authorization immediately is revoked.
The other part of it is the experience with the drugs that we have. If you stop the systemic, at some point the disease is going to come back. Peter has published—and I agree with him—that with the biologics, the data show you can give people a long-term remission. If they have done wonderfully and are clear, a lot of times, if they stop and you pick dupilumab, it might be 3 to 6 months or even longer before the disease comes back. But it’s going to come back. I always think in terms of infection risk in these patients. If we wait until the disease starts to flare, and before we restart therapy, they’ve already been through the high-risk period for getting a skin infection that can turn into something serious.
Raj Chovatiya, MD, PhD: Dr Noor, you’re no stranger to getting many things on board to get someone under control. How does the idea of monotherapy and combination therapies play a role in what you’re doing, especially for someone who’s transitioned up the severity ladder? As Matt told us, combination therapy is the most indicative of what’s happening in the real world. Tell us about your practice.
Omar Noor, MD: One thing that’s very consistent with essentially every patient in my practice is that I look them in the face and say, “I’m going to get you better.” I can get you better because I have all these options, and these options are extensive. We have wonderful options, all the way down to cyclosporine and methotrexate, and the ability to combine different treatments. If we can appreciate the data, if we can appreciate the safety, then we can appreciate what to expect that this individual needs.
One thing that I always stand by, and it’s going to sound silly, is that I’m not a vending machine. I don’t do the same thing for each individual. It’s not like you come in, you punch in a button and say, “I have moderate atopic dermatitis,” and out comes your drug. That’s not how it works. Every patient is an individual, and I treat everybody individually to make sure I get the best possible outcome for that individual. Every patient knows that, in every room and in every scenario. If that means that they need to go on a biologic and a topical, like ruxolitinib; a biologic; or even an oral JAK inhibitor, then I’m going to take that situation individually and determine the best option for that patient.
Transcript edited for clarity