Personalizing Treatment Selection in Atopic Dermatitis - Episode 7
Matthew Zirwas, MD, and Omar Noor, MD, review a patient scenario where AD disease activity is limited but in difficult to treat locations.
Raj Chovatiya, MD, PhD: Thinking about clinical scenarios, adverse effects from topical corticosteroids are one thing that’s on my mind as much as yours. What about if you have a patient, let’s say, with pretty limited disease activity, but at least moderate in nature, that’s in a difficult to treat location? We’re thinking about somebody who has chronic hand eczema, maybe a chef or a new mother who needs to wash her hands often. Perhaps it’s the genital region where you’re focusing, or an inverse distribution in the inguinal and axillary vault as well. What challenges might patients face in controlling their disease there, Dr Zirwas?
Matthew Zirwas, MD: The big challenge is, we’ve got topical steroids of course. The challenge, especially with hand eczema, is the least appreciated adverse effect of topical steroids is barrier impairment. With 3 days of topical steroid use, you get essentially an elimination of lamellar body production and secretion, and so you get significant impairment of barrier recovery. For hand eczema, it’s a real challenge to use topical steroids for an irritant dermatitis.
For some of the other challenging areas, those are areas where we are particularly worried about steroid adverse effects, things like atrophy and stretch marks. In areas of thinning skin, things like perioral dermatitis, and maybe glaucoma and cataracts where we use medication on the face. Those are patients for whom I try to go to nonsteroidal therapy as quickly and early as I can.
The challenge with the drugs we’ve had for a long time, such as pimecrolimus and tacrolimus, for pimecrolimus, you don’t see a whole lot of burning with it, but you also don’t see a whole lot of efficacy with it, and it has propylene glycol in the vehicle. While tacrolimus has more efficacy, it’s relatively slow. Patients often have to use it for several days or a week before they’ll see much benefit, and the rates of burning are pretty high, and for people who get the burning, it can be fairly intense. So that presents a real challenge.
Then we’ve got crisaborole, and the challenge there is very high rates of stinging and burning with application, and then again, not the most effective agent. That leaves us with topical ruxolitinib, which is in my experience a stunningly fast and effective drug. I think of it as clobetasol without any adverse effects. It really has been a game changer in treating sensitive skin areas, areas where we’re concerned about using topical steroids, like hand eczema, because we don’t get the barrier impairment that we get with topical steroids. It really has been a game changer for patients with atopic dermatitis in what I would call sensitive skin areas.
Raj Chovatiya, MD, PhD: Building off of that, Dr Noor, does quickness guide your response here? Is that something you talk about with patients? Is it not on the top of your mind? Is it something that patients talk about, but we don’t really think about much? What types of data do you like to review with your patients when making that treatment selection, and how does that inform what treatment you might select for somebody?
Omar Noor, MD: Dr Hebert mentioned it earlier, when these patients are on oral steroids and they’re getting better faster, but then they’re having a rebound. It’s difficult for us to appease these kind of steroid monsters because they get so used to such a fast result. I think as we better appreciate this JAK-STAT mechanism, we’re seeing, and I’m telling my patients this, go on topical ruxolitinib and you’re seeing itch reduction within a day. It makes me feel comfortable to tell my patients that it attacks that steroid monster and gives them something they can then appreciate. We can talk about how just like with every medication, we have to have discussions around potential adverse events, potential adverse effects. But I agree with Dr Zirwas that the adverse effect profile for ruxolitinib, I’m very comfortable with. Then from an efficacy and speed perspective, that’s the No. 1 thing I talk about with my patients. I want to give them a framework, a structure of what to expect from an efficacy and speed perspective because that’s what they’re going to see. And like I said, I’m seeing improvement within a day.
Transcript edited for clarity