Personalizing Treatment Selection in Atopic Dermatitis - Episode 10
Matthew Zirwas, MD, and Omar Noor, MD, comment on their own experience of time to response with topical and systemic treatments of AD.
Raj Chovatiya, MD, PhD: As someone else who’s been in many of these studies, Matt, I want to pick your brain for a second again, particularly with all these options, when it comes to time to treatment and how fast they work. We’ve heard a lot about topical ruxolitinib, but how does this stack up with a lot of the other topical options we have in our toolbox right now, particularly thinking about making a dent in the itch and the lesional clearance?
Matthew Zirwas, MD: Whenever I’m talking about topicals, I’m always trying to underpromise and over-deliver a bit. I’ll tell patients that with a TCI [topical calcineurin inhibitor], so with pimecrolimus or tacrolimus or with crisaborole, I generally tell people, “You might have to use this for a week before it starts working,” because I don’t want them to give up after 3 or 4 days if they’re not seeing benefit. I want them to give it a full week before they see if they’re starting to get benefit with it. With topical steroids, people usually already have a good sense of that, but I tend to think of topical steroids as having some efficacy starting the next day, maybe even the day of application.
Now in some instances, topical steroids don’t always work, and so there are some cases where they never have efficacy. But generally, I think of topical steroids as working in 12 to 24 hours, starting to see benefit. I think with topical ruxolitinib, it’s the same thing. I tend to think of topical ruxolitinib as having efficacy many patients will tell me the day they put it on, by that night there’s a meaningful change in their itch, something I’ve heard over and over from patients. I think of topical ruxolitinib as being as fast or faster than topical steroids. I don’t know that we have data to back that up, but that’s the impression I get from patients. And again, that goes to why I think it gives patients this sense of control over their disease.
Raj Chovatiya, MD, PhD: Dr Noor, I’ll bounce the same thing to you. How do you think about the differences in terms of speed of onset and efficacy with the topicals when you’re having a discussion with your patients, knowing the data behind all of them and your own real-world practice?
Omar Noor, MD: Before topical ruxolitinib first became available in our practice [Penn Medicine in Philadelphia, Pennsylvania], we used tacrolimus, pimecrolimus, and crisaborole, and it is always very interesting to see the transition our practice has had. A lot of times, we would have used a topical steroid twice a day, 2 weeks on, 2 weeks off. And a lot of times I would tell the patients, “In those 2 weeks off, in order to avoid the atrophy striae and impart a sense of safety around the topical steroid, we will utilize tacrolimus,” for instance. The reason we would say that is a lot of time, the patients need something to do. I am not telling them to use tacrolimus because of its effectiveness; a lot of times in those scenarios, I was using tacrolimus just as a crutch to get us back to the topical steroid, which we know could be effective in the right way.
Now since I’ve been using topical ruxolitinib in my practice for my patients with atopic dermatitis, I use it as monotherapy. I’m using it to say, “Here’s an option for you. This is going to help with your eczema, this is going to help with your itch. It’s going to working quickly, and it’s safe to use from the head down in any area that you want.” And I’m not prescribing the topical corticosteroids in combination with it. I’m using it, and what my staff has noticed, and I have noticed, is that inherently now I’m prescribing fewer topical steroids overall, and that has changed my practice quite a bit.
Raj Chovatiya, MD, PhD: I think the fact that you can teach all of us new tricks over time is nice to think about. Because there’s this idea that once you’ve been practicing for a couple years, you end up being stubborn with your practice habits. With atopic dermatitis in one sense, I think it’s almost a different discussion because there were such limited treatments to begin with, I think almost everybody created something different to use, knowing how prevalent the disease is, when they’re talking about at any given time about 10% of the United States population. And the fact that we had topical corticosteroid in the systemic fashion, methotrexate, cyclosporine, and that’s about it. I think hopefully a lot of this innovation ends up, much as you do in your practice, noticing that you’re shifting how you do stuff very quickly in real time.
Transcript edited for clarity