Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 6

Systemic Therapies for Atopic Dermatitis

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The rationale for using systemic therapies such as methotrexate, azathioprine, phototherapy, or others to treat patients with severe, persistent atopic dermatitis.

Melodie Young, MSN, RN, ANP-C [Mindful Dermatology and Modern Research Associates Dallas, Texas]: One of the unique things about dermatology is the learning about how to use topical therapies, teach about topical therapies, and prescribe the right things. Deciding whether it's a cream or an ointment or a spray or a foam, the multitude [of therapies] is one of the most challenging things whenever there's somebody new that's coming into the field, or if you have a student. They're always saying, "Well, when do you know how much to give?" There are things like the Long and Finlay fingertip unit (FTU) and some other guides that help you sort out how much medicine, how big a jar, how large a tube, and the tube that you would use. We all have fears and patients have the fear of undertreatment and just keep applying topical treatments because it's the only thing that would give them relief. Douglas, I think you're prepared to speak to some of the newer things that we're having more of a systemic approach in treating atopic dermatitis as much the way we have with the evolution of care in the psoriatic patients. We've had some systemic agents that we've used off-label. If you could speak to that and then we'll start talking about some of the newer emerging therapies.

Douglas DiRuggiero, DMSc, PA-C [Skin Cancer and Cosmetic Dermatology Center, Rome, Georgia]: I think we would all agree that when practicing dermatology, we tend to be more aggressive than our primary care counterparts. While they may not have this level of training we have at handling atopic dermatitis and other eczema responses, they do often have a healthy respect for thinning of the skin. Where that gets lost is that their staff can tend to overprescribe, giving refills on call-ins, and patients stay on it forever. In general, we're more aggressive, using higher potency class 1 steroids for short bursts of time when pediatricians wouldn't feel comfortable. We're going to be more aggressive with systemic therapies as well. We do have and have used the old demarche for atopic dermatitis and those classical disease-modifying anti-rheumatic drugs, like methotrexate, mirtazapine, cyclosporine, with patients.

More adults than in kids, but there's even a robust amount of data on using methotrexate in kids all the way down to age four. In some countries’ multiple studies, there are prescribing guidelines on how to do that and what side effects to look out for. I don't find that we see as much of that being used here in the U S, particularly in last decade with the onset of all these newer treatments. Because these medications do have a lot of side effects, blood drawl and lab marching that you have to have. If parents are afraid of giving a child something that's injectable, I say, "Well, a lot of the old treatments are not going to make your child avoid a needle, because we have to draw blood to monitor their blood work." It's not a needle-free adventure on most of these oral treatments because we have to monitor blood work in order to keep an eye on it. The most common systemic is prednisone. Prednisone is like the elephant in the room with all atopic treatments because these kids go into ERs, urgent care centers ,and medicine shops and then leave with Medrol Dosepaks, or 40 mg of prednisone for ten days. All of us have used it in our clinic and used it for rescue therapy on our own. I'm not trying to throw them under the bus, but it's common there. We have to say that oral prednisone is overutilized because we see rebound flares and they’re difficult to manage.

It should be something that's an absolute rescue therapy in the dermatology space, and it's overused in the non-dermatology space. Lastly, phototherapy has a lot of robust data on use in this patient population with good suppression. There's a lot of hesitancy because of the potential risk of increase in melanoma and nonmelanoma skin cancers later in life. We know that it can be beneficial from the anti-inflammatory effects of that wavelength of light that's coming through. I think that's methotrexate, azathioprine, prednisone, and phototherapy would be considered all traditional, systemic, or nontopical treatments that we are looking over our shoulder at now as opposed to looking ahead to what we currently have and what's about to come.

Melodie Young, MSN, RN, ANP-C: Thank you for watching this HCPLive® Peer Exchange. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming peer exchange segments and other great content right in your inbox.

Transcript Edited for Clarity