Personalizing Treatment Selection in Atopic Dermatitis - Episode 3

Patient on Long-Term Steroidal Use in AD

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Adelaide A. Hebert, MD, reviews the use of long-term steroids for treatment of atopic dermatitis.

Raj Chovatiya, MD, PhD: That leads to our first clinical scenario, which I want everybody to weigh in on. Imagine that there’s a patient who you’ve been seeing for years or who has had atopic dermatitis for years with the disease in multiple areas, on their face and neck included. They’ve been on topical corticosteroids for a long period of time, and now they’re starting to experience some adverse effects from topical corticosteroid usage. You can insert anything you want in there.

Adelaide, when you’re thinking about topicals—you see pediatric patients quite a bit, so this is an important question—how long are you recommending them to patients? Are there guidelines you follow? Are there things you prepare your patients for? How do you handle the topical corticosteroid discussion, particularly in people who are starting to experience issues from long-term use?

Adelaide A. Hebert, MD: I’ve been at this institution [The University of Texas Health Science Center at Houston] for 38 years. I’ve had patients who’ve had long-term steroid use. We don’t have the full realm of these new therapies in the pediatric arena. We have some, and we hope that we’ll have studies that will bring many new medicines to younger pediatric patients. We have 1 biologic that goes down to the very youngest. We have 1 topical that goes down to 12-year-olds. But the rest of the drugs pertain to older patients. We hope that changes. We have 1 pill, also—1 JAK inhibitor—that goes down to age 12.

In terms of long-term steroid use, my advice is to feel the area. Don’t just look at the area. If they can feel spongiotic dermatitis, if they feel the bumpy rash, then you can use the steroid. But if they’re experiencing postinflammatory or steroid-induced hypopigmentation, they may or may not follow that guidance. Try to use steroids appropriately, with the correct concentrations for the trunk and extremities and a lower concentration for face or astringent areas. We provide all that guidance.

I don’t have any firm rules, but I limit the amount that I give them so that I know they’re not using them excessively. We see our patients back with atopic dermatitis, not only when they flare but also to get an idea of how they’re doing and to give them updates about these exciting medications that are forthcoming. Parents love to hear about how much the atopic dermatitis landscape, in terms of therapy, has changed. We give the best guidance we can for topical steroids. We don’t want to have overuse based on some of the studies on compliance. We have to worry about that less than we think we do because patients don’t use them often enough. We haven’t talked about the use of moisturizers. I’m assuming we will, but those are part of the foundational education that we provide for patients. Many times, if they use proper moisturization, bathing technique, and skin care, they need fewer steroids in the long run.

Raj Chovatiya, MD, PhD: That’s a great point.

Transcript edited for clarity