Dr Alexis shares how he creates care plans for his patients with atopic dermatitis and shares insights on the current and future therapies.
Patients do not neatly fit into severity categories for atopic dermatitis (AD) in real-world practice. I actually make a distinction on whether a patient’s disease can be managed effectively on topical therapy, or if it is beyond what topical therapy reasonably can do and requires a nontopical approach. Deciding on the appropriate therapy in discussions with patients depends on a number of factors, including patient lifestyle and comorbidities, but ultimately, dermatologists should most heavily weigh the impact of the AD on the patient and how well it is controlled with current therapies.
Though I do not use it exclusively to determine a care plan, body surface area (BSA) can play a role in this decision. For example, in a case that affects a larger BSA, topical therapy can be less practical for the patient. But a patient with limited BSA in a highly visible or high function area, such as the face or hands, may be a good candidate for nontopical therapy if the AD severely impacts quality of life.
These situations, in particular, highlight how there really is no neat formula to easily use to determine what classifies as moderate to severe or who would be a candidate for nontopical therapy. So, I recommend taking every patient on an individual basis, assessing multiple factors such as clinical severity, BSA, and asking questions about potential impact on their quality of life and function.
Barriers to Care
Patient awareness and education about the chronic nature of AD can be a major barrier to appropriate care. There are sometimes gaps in understanding that AD is a disease that needs to be managed over the long term. The roller coaster ride of flaring, getting a quick fix to clear up, and then waiting until the next flare is a suboptimal approach to a chronic, relapsing condition. Patients may not realize that this method can wreak havoc on overall daily life and function. The next big flare can come with sleepless nights, canceling social engagements, and impacted performance at work or school, including taking time away from those environments to seek care.
Dermatologists, and other specialties that may be the first to see a patient with AD, need to educate patients and give them access to optimal care such that they can effectively manage their condition longitudinally. We should work with patients to minimize the frequency and severity of flares.
I like to emphasize in the initial visit and reiterate in subsequent visits that the care plan is a long-term strategy that may change as the condition or other health-related or personal factors evolve. Therapy is a dynamic process, and we will adjust our approach according to what is needed to control the condition at any given time. We need to further explain to patients that AD is more than just putting out the initial AD flare that brought them into the doctor’s office. We want to prevent further flares in the future. So, in addition to pharmacologic therapy, we have to recommend appropriate bathing and moisturization practices as part of a comprehensive care plan.
Future of Care
This is a very exciting time in AD, because there are so many potential breakthrough therapies on the horizon. Various Janus kinase (Jak) inhibitors, both oral and topical, are in development and show great promise for AD. These include upadacitinib, baricitinib, and abrocitinib as oral Jak options and delgocitinib and ruxolitinib as topical Jaks. One of the aspects of Jak inhibitors that makes them particularly exciting is that not only can they be administered orally or topically but also, especially in the case of oral Jaks, there is a rapidity of response both for clinical severity and itch, which is the most burdensome symptom in AD. The opportunity to be able to see rapid and sustained reductions in symptoms, especially with itch, is very advantageous.
We should also touch on IL-31 antagonism with nemolizumab. This is exciting as well, given the potential role of IL-31 in not only improving the signs and symptoms of AD on the whole but specifically improving itch. IL-13 continues to be a therapeutic target, with the biologic agents tralokinumab and lebrikizumab in development as potential options in targeting this pathway in addition to the FDA-approved dual IL-4/IL-13 antagonist dupliumab.
With this great number of options in the pipeline, practitioners will have more tools to address moderate to severe AD.
Dr Alexis is professor and chair of dermatology at Mount Sinai West and Mount Sinai Morningside, and the director of the Skin of Color Center in New York City, NY.
Disclosure: Dr Alexis has received grant/research support (funds to institution) from Leo Pharma, Novartis, Almirall, Bristol Myers Squibb, Celgene, Menlo, Galderma, Bausch Health, and Cara, and he has served as a consultant/advisory board member for Leo Pharma, Novartis, Menlo, Galderma, Pfizer, Sanofi-Regeneron, Dermavant, Unilever, Celgene, Beiersdorf, L’Oreal, Bristol Myers Squibb, Menlo, Scientis, Bausch Health, UCB, and Foamix.