Practical Management of Atopic Dermatitis: Nurse Practitioner and Physician Assistant Perspectives - Episode 5
Best practices using topical therapies to treat atopic dermatitis and managing treatment-related adverse events.
Melodie Young, MSN, RN, ANP-C [Mindful Dermatology and Modern Research Associates Dallas, Texas]: Let's move on to pharmacologic interventions and medicinal things that we would prescribe or recommend. Susan, you have more longevity as an expert on this disease than pretty much any other nurse practitioner [NP] or PA (physician’s assistant) in the country than I'm aware of. I know that it's been fun for you to see the evolution from corticosteroids to, now, a multitude of other topicals and other things that come. Do you want to just kind of introduce us to some of the topical therapies that we have available?
Susan Tofte, DNP, MS, FNP-C [Oregon Health & Science University, Portland, Oregon]: The mainstay are topical corticosteroids. In my practice, I will often explain to a patient that there is just a handful of super potent topical steroid. There's a lot of middle-of-the-road ones. Then, there's a handful of very weak ones that I usually say, "You can buy those over-the-counter. They're not worth your time and money," because for somebody who's really inflamed, the 1% hydrocortisone is really not going to do anything. Topical steroids have really been the mainstay. For somebody who is not severe total-body, if they have just flexural areas involved, they're pretty localized, this is a very effective treatment. Usually, for most patients, at least where I live, if they're in a flare-up and it's kind of a localized flare, taking a bath if they can twice a day. That's not possible for a lot of people, but at least getting in the water once a day. As Keri said, while the skin is still moist, put your topical steroid on those areas. I will treat with a mid-strength steroid, something like triamcinolone 0.1%. We always recommend ointments over creams because they're better tolerated and they get in the skin better. I'll have them use it twice a day for areas on the body for 7 days, maybe a little bit longer for certain persistent areas.
I try to reserve those super-potent topical steroids for really thick, cornified areas on the hands, feet, wrists, or ankles. In patients, studies have shown that using a mid-strength steroid 2 days a week long-term on just localized areas is effective. I usually tell patients to do it on Monday and Friday or Tuesday and Saturday, and long-term. Using their emollients in-between regularly can be a really good treatment plan for a patient over the long haul. More than a decade ago, we were introduced to topical, nonsteroidal-anti-inflammatories, and there are three on the market: Protopic or tacrolimus, pimecrolimus or Elidel, and Eucrisa or crisaborole. These are used well in combination with topical corticosteroids, but the key to prescribing is taking the time to educate your patients about the common side effects of those drugs, because they do cause burning and stinging. For adult patients, it will be for several days. If you don't tell them that they're going to have burning and stinging, they will stop as soon as they have that side effect and think that you've given them something terrible for their skin. It's important to take the time to educate them about that, but because they're nonsteroidal, they are very safe to use on the face.
I usually tell patients that the thinnest skin on our body are our upper eyelids and then face, neck, axilla, breasts, groin, and buttocks. These are ideal medications to use in those places where you can't use topical corticosteroids long-term. Long-term and inappropriate use of a topical steroid will lead to thinning of your skin and side effects that you don't want. You need to emphasize what gets to be used where, where it's safe to use it, and how long it's safe to use it. My last bullet point on that is that if you have a patient with a lot of areas, like a big person or a big patient, don't under prescribe the quantity. Give them enough to treat, and especially if they're coming in close to a weekend or holiday weekend, they don't want to run out of their medication if they should get into a big flare-up. Keri mentioned that sometimes you don't know what triggers it and when they're going to get a flare-up. It could be unpredictable. A patient never wants to be without a topical steroid if that is how they're going to be managed.
Melodie Young, MSN, RN, ANP-C: How do you manage the complaints of the side effects with the nonsteroidals like sort of that peppering sensation?
Susan Tofte, DNP, MS, FNP-C: It's hard. I'm part of our research team and I did all of the clinical trials early on with Protopic and Elidel and the ones with Eucrisa. It’s recommended that they can get up to using it twice a day, but it can cause increased itching. I might start out by using it once a day and in combination with a topical steroid, and sometimes that will settle it down. Generally, people get past it after a few days or a week of treatment. I tell them to hang in there, but not everybody can do it. I have found that crisaborole, or Eucrisa, has probably the profile with the most stinging and burning; patients complain the most about that. Elidel is a cream vehicle, so it's less shiny and greasy and it's FDA approved for mild to moderate disease. The burning effect is maybe a little bit less for that. Protopic has 2 strengths. Either the 0.1 concentration or the 0.03. The lower concentration of Protopic may have less side effects than the higher concentration.
Melodie Young, MSN, RN, ANP-C: It also can affect efficacy as well at the lower strength.
Keri Holyoak, PA-C, MPH [Dermatology Center of Salt Lake, Midvale, Utah]: I find that the thing you worry about happens more on the face, and if we put it in the fridge, that can often take the edge off of it. The reason it stings and burns is because of that release of substance P (SP), and that tells our patients that they know it's working. Most of the stinging and burning is manageable as long as you set those expectations up front.
Melodie Young, MSN, RN, ANP-C: Douglas, do you have any comments for or against the views?
Douglas DiRuggiero, DMSc, PA-C [Skin Cancer and Cosmetic Dermatology Center, Rome, Georgia]: An excellent breakdown by Susan on those topical products. I split the history of dermatology into one pivotal timeframe and that is 1952. I call it BC versus AC—before cortisone and after cortisone—because when Marion Sulzberger first put cortisone on the first patient with eczema in 1952, it changed forever the way we do things. Now we're seeing this new renaissance of treatments that are beyond topicals that is just equivalent to what was happening there in the 1950s, as that first prescription strength cortisone was utilized and published. The only thing I have to add is that we do have some age requirements for some of those creams you mentioned. You should look into the bag, it's now available to you and even though there's some debate on whether or not that should be legitimate or should be taken out of the package insert, it still sits there. I find that when I use a ceramide-rich moisturizer, that I see less burning than when they're using any other types of moisturizers.
We know from looking at evidence-based medicine, that Rawlins’ seminal pivotal study (2014) in the British journal, looked at isolating that ceramide 1 and [ceramide] 3 deficiency in atopic dermatitis [AD] kids. That's what gave us all these ceramides and ceramax and all these ones that are trying to replenish ceramides. When I combine those with ceramide-rich moisturizers, as opposed to nonceramide-rich, I see a little less stinging complaints, or I rarely see it. I have to transition them over with steroids at the same time. If they're on steroids and they come in, you want to get them off steroids and have them overlap for a little while or else they're going to always perceive it as a stinging.
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 in-box.
Transcript Edited for Clarity