Management of Type 2 Inflammation in Atopic Dermatitis - Episode 4
Moving on to discuss treatment options for patients with atopic dermatitis, experts reflect on optimal use of topical agents in this setting.
Peter A. Lio, MD: Dr Jain, what about you when you’re thinking about that shared decision-making process? I guess the last piece for this is you mentioned some of the barriers, and to me, one of the big barriers you brought up was accessibility. Can you afford the treatment? That’s huge.
Another one is the perception of safety, and that’s something that I’m dealing with a lot right now. A lot of my patients come in and the discussion begins with “I don’t want any steroids” because they’re afraid of them. They’re worried about them, or “I don’t want antibiotics.” All these kinds of things.
I feel like we enter a little bit of this mind field. For me, I like to tell the story. I like to say where they came from. I always like to try to emphasize the risk of not treating the disease too because we’re very good at talking about the risks of medicine but if you don’t treat [the disease], there’s still a big risk, right?
With atopic dermatitis, it’s not only the pure suffering, but I think there’s a very real possibility that letting atopic dermatitis go untreated or undertreated can lead to more allergic comorbidities.
We have the beautiful work from Professor Gideon Lack [Pediatric Allergy at Kings College London] with the LEAP study, suggesting that it is transcutaneous or epicutaneous sensitization of allergens. I like to tell that story and then I like to guide them to some different options and kind of feel them out.
I also love the idea of thinking about both acute flare-ups. What are we going to do when you’re flaring? Then more of a controller or more of when you’re better, a maintenance or proactive approach. I always tell my patients too, for some people it is controllable just being reactive.
There are patients who could look bad, but all you do is you put a little steroid on for a few days and it’s better. For those people, that might be all we need to do if they’re safely able to use topical steroids. But for the people that either can’t get clear with that or much more commonly are not staying clear safely, they’re either overusing those steroids or they’re having enough trouble that we need to think out of the box.
That segues us into the next piece here, which is thinking about our options. I think topical steroids for better, or for worse, still are the mainstay. They’re where we begin because I think they’re the perfect trifecta of extremely affordable/accessible. They’re very reliably effective. They help almost everybody.
It’s very rare that a patient says it didn’t do a thing, and then they are safe, relatively speaking. They certainly have important safety concerns, but I think we begin there.
Then, when we need to go outside of that, from a topical standpoint, we have our calcineurin inhibitors, which have been around since 2000 and 2001, respectively, tacrolimus and pimecrolimus [Elidel]. Those have been very, very good steroids that we’ve had.
Then, in 2016, we got our next new medicine, which was our topical phosphodiesterase 4 [PDE4] inhibitors, crisaborole [Eurcrisa], the emphasis on BO for boron. That was important as well because that has no black box warning. Very safe. Of course, now that one’s approved down to 3 months of age so while I think of it as a much milder treatment, it doesn’t have the same tick as the other ones. It’s safe.
Then just in the past few months, we got our first new agent in a long time, our first topical JAK [Janus kinase] inhibitor, topical ruxolitinib [Jakafi]. That’s neat because I feel that has been something that at least in my limited experience so far seems to the punch of topical steroids or nearly so, but with a different side effect profile and in some ways better.
I’m not sure it’s necessarily better overall than steroids. Of course, it’s much more expensive, but I really enjoy it as something that we can alternate. I can say, “OK, we can use our steroid for a little bit. If we’re overusing, we can now use this more powerful agent for those people who need it.”
Then, of course, once we get to those options, that brings us up to our systemic agents, but let me stop there. Let’s talk about topicals. When you guys are approaching a patient with topicals, do you still start with steroids, or do you sometimes try to start with one of the nonsteroidal agents?
Neal Jain, MD: I think it really depends on the patient and what they’ve tried and perhaps failed or had success with in the past. I think you had mentioned some of these newer agents and certainly, older agents that we’ve had for 20 years now, like topical calcineurin inhibitors, and you think about the location of the disease.
Do they have eyelid dermatitis that is associated with their bad allergic rhinitis, and do they have seasonal players? Might I think about using something like ruxolitinib or a topical calcineurin inhibitor in a patient that has more facial or eye dermatitis where you really don’t want to maybe use a topical steroid continually, or if someone has already tried to use that and has been using that consistently?
Certainly, I would agree this is all worth the mainstay. The backstop that we’ve always sort of relied on are those topical steroids because they are so reliably effective. Again, I would emphasize that we really need to think about the fundamental skincare, the soak and smear, the use of emollients, and then sort of adding these on top.
Then when those are not working or they’re insufficient where you’ve got such significant body surface area or again, as you said, you’re a guide, we’re a Sherpa. We’re a Sherpa to these patients and we ask them, what are your goals? What is it that you want to achieve? Are we achieving those goals? Are we achieving that ADCS of 7 or less? If we’re not, then we need to think about stepping up to these other therapies.
Matt Feldman, MD: I would agree. I would add to our list that we talked about, not necessarily something that packs the punch like Dr Lio said, like ruxolitinib or like topical calcineurin inhibitors, but quickly for a subset of my patients or families where they really are topical steroid phobic and maybe sometimes need a little convincing to be on a topical steroid or a topical calcineurin inhibitor.
Maybe they tried the PDE4 inhibitor and had some side effects topically or locally or lack of response. The high content ceramides that are available by prescription occasionally may help. Or you could at least say, “Look, we tried something that was a little bit different, and it didn’t work. So maybe it’s now time to bite the bullet and try 1 of these topical steroids or topical calcineurin inhibitors.”
We’ve got to meet our patients in the middle and find a compromise and try something that you maybe don’t have as much confidence in the punch that it’ll bring to help clear the flare.
You might be surprised A, it may help, or B, it may help with buy-in with the patient in the future, as you’re trying to convince them to try other therapies like the newer therapies, ruxolitinib, etc.
Transcript edited for clarity.