Lindsay Strowd, MD, discusses some of the latest advances in topical therapies for the treatment of atopic dermatitis and shares her tips on using topicals to manage this disease.
Dr Strowd is an associate professor of dermatology at Wake Forest Medical School in Winston-Salem, North Carolina.
Melissa: Hello, everyone. Today, I’ll be speaking with Dr Lindsay Strowd. Dr Strowd is an associate professor of dermatology at Wake Forest School of Medicine in Winston‑Salem, North Carolina. Today, she will be discussing some of the latest updates in topical therapies for atopic dermatitis.
Thank you for joining us today, Dr Strowd. What are some of the latest advances in topical therapy for atopic dermatitis, including newer options in the pipeline?
Dr Lindsay Strowd: For atopic dermatitis, we’ve obviously had a lot of experience using different topical corticosteroids, which have been approved for many years. I would say regarding newer medicines to come to market, we had the topical calcineurin inhibitors that were approved several years ago for use in atopic dermatitis. A more recent FDA‑approved medication is topical crisaborole, or Eurcrisa, which has been approved now for ages 3 months and older for use in mild to moderate atopic dermatitis.
We do have multiple, different, non‑steroidal, topical anti‑inflammatory medications that we can use for patients with atopic dermatitis. However, by and large, the topical treatment landscape is still somewhat narrow. There is room for additional, particularly non‑steroidal, options that we can offer for our patients.
To my knowledge, some of the focus more recently has been on topical JAK inhibitors, or topical Janus kinase inhibitors. Janus kinase inhibitors have been researched both in a topical format for use in atopic dermatitis, but also as a topical medication for other skin diseases, and also as an oral medication for treatment for more severe atopic dermatitis as well.
I believe topical tofacitinib is a topical JAK inhibitor that’s currently undergoing research and clinical trials to determine its efficacy in the use of atopic dermatitis.
My hope, and the hope for a lot of people that treat many patients with atopic dermatitis, is that in the next couple of years we’ll have even more options for our patients, particularly in the realm of non‑steroidal, topical therapeutic options.
Melissa: How has the addition of crisaborole impacted the treatment of atopic dermatitis?
Dr Strowd: Crisaborole, or Eurcrisa, is the newest FDA‑approved medication for atopic dermatitis, and it’s one that has expanded our armamentarium of non‑steroidal medications to use in our patients. It’s important for our patients to have options, and so, it’s a nice alternative therapy to the topical calcineurin inhibitors. Again, it’s limited in terms of it’s not going to be effective for a more severe patient. It is, by and large, used in more mild atopic dermatitis.
One of the issues with Eurcrisa is some of the application site burning that some of our patients can experience, which is also something that we do see with the topical calcineurin inhibitors as well. If that side effect can be managed, then it’s a good option for patients. It’s always nice for us to have more options for our patients. It’s a positive addition to our current treatment paradigm that we have.
Melissa: Topical calcineurin inhibitors have a black box warning for cancer, which could cause some concern among patients and parents. How do you counsel them on the safety of these therapies?
Dr Strowd: Many patients, particularly pediatric patients, when they come into the office, they’re accompanied by a caregiver or a parent. Some of the concerns that I run into commonly with parents revolve around a couple of different aspects of treatment for atopic dermatitis. One of them is a fear of long‑term use of topical corticosteroids.
Many parents are wary of using topical steroids on their children for long periods of time. It is nice for us to be able to utilize some of our other treatment options outside of topical steroids, particularly when patients have that concern.
One of the other concerns, however, that we run into involves some of the warnings that come with the topical calcineurin inhibitor products. Specifically, there is a black box warning on the topical calcineurin inhibitors related to potential risk of developing of lymphoma.
When parents see that, obviously, they’re very concerned and are not sure that they want to use that medication on their children. I always think that it’s better to bring that up with parents at the initial visit rather than have them discover that on their own and then come back to see you in follow‑up and voice those concerns.
If I’m going to prescribe a topical calcineurin inhibitor, I usually will tell parents that it does have this warning on it, and that there’ve been pretty large studies looking at the risk of things like lymphoma in patients that use topical calcineurin inhibitors. The risk is extremely low, and so, it’s not a concern of mine personally.
I think that, by and large, those medications are very safe alternatives. They’re very large molecules, and so, there’s pretty minimal systemic absorption of those types of medications in patients when used properly.
Educating on proper use of the medication can also help, in addition to letting parents know that that label is on the product, so that they’re not surprised when they get to the pharmacy and pick up the medication and see it for the first time.
Melissa: What are your tips for managing atopic dermatitis with topical therapies?
Dr Strowd: One of the hard things about treating atopic dermatitis is trying to figure out what treatment regimen is going to work well for any individual patient.
There’s a lot of different things that you have to factor in. Everything from a patient’s insurance to the age of the patient, what their social situation is to the degree of the atopic dermatitis, their motivation to get better, all of these things play a role in deciding what type of regimen you want to advocate for your patient.
I do find, by and large, that trying to keep regimens as simple as possible is usually a good strategy, especially when you’re working with younger patients and our adolescent patient population as well.
There’s good data that shows that the more prescriptions you provide to a patient, particularly when it comes to topical medications, the less adherent they become. I’m a big fan of trying to use one topical agent for the body and then using another topical agent for the face, starting there and trying to keep it as simple and easy to follow as possible.
When you start getting into using multiple, different topical medications— four, five, six topical medications—it becomes overwhelming to patients. They oftentimes feel like they can’t keep up with the regimen, and therefore, they don’t do well on the end result.
We also talk to our patients about trying to treat by feel. Using the medication when the eczema or the atopic dermatitis feels active, when the skin feels different in texture from normal, that’s when you get the green light to use your medication.
Once that skin starts to feel more like your normal skin then you can stop using the product at that point and just continue with your daily moisturization of the skin.
Treating by feel also helps patients get an understanding for when they should be using the products and when they shouldn’t.
Melissa: What other considerations should dermatologists keep in mind to ensure patients are set up for success?
Dr Strowd: Things that we certainly talk about with our residents and our fellow colleagues that manage atopic dermatitis is it’s important to have that shared medical decision‑making with your patients. Patients are going to be much more likely to want to follow their treatment regimen and their treatment outline if they’ve had an active role in creating that regimen.
I feel like it’s worth the time spent upfront in that office visit with the patient to give them all the different options and let them pick and choose things that would work well for their individual life and their treatment goals. When they feel like they’ve contributed to the decision then they feel like they’ve got a stake in the game, as you will.
Some common pitfalls that we run into is not asking about vehicle preference for patients. There’s some patients that prefer more of an ointment‑based product, whereas other patients can’t tolerate ointments. Having that conversation helps avoid prescribing something that a patient isn’t going to like the feel of, and therefore, isn’t going to use.
Establishing what patient’s goals are for treatment at the outset is also going to be helpful in determining how aggressive of a treatment regimen you want to develop for that patient, and also making sure that you’re addressing all of the issues that the patient has.
If sleep disturbance is a main concern for that patient, if you don’t get that at the outset, then you may not adequately address that part of their disease process.
Overall, I would just say that spending the time upfront to get to know your patient, to talk about their goals of care and their personal preferences in terms of treatment pays dividends in the end. Patients end up being much more adherent and buy into what you’re doing to a higher degree.
Melissa: Are there any other thoughts or comments you would like to add?
Dr Strowd: Just in general, atopic dermatitis is a very fascinating disease to study and a very rewarding one to treat for our patients, both young and old. The field is very dynamic right now with regards to new clinical trials, new medications, new therapeutic targets that are being developed.
It is an area within dermatology that we’re going to see a lot of change over the next couple of years. That’s very exciting, both for us as providers, but also for our patients as well. As we look to the future, we can be excited by the possibilities of having even more efficacious treatments for our patients.
Melissa: Thank you so much for joining us, Dr Strowd, and thank you for listening. If you have any additional questions or comments, please leave them in the feedback box below. We really appreciate your feedback. Thank you.