VIDEO: Treatment considerations for atopic dermatitis based on disease severity

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The approach to mild to moderate atopic dermatitis is different from that of moderate to severe. There are algorithms galore but they all start no matter what the severity with good moisturization on a regular basis, particularly after bathing or showering and avoidance of irritants. For those who have really mild disease we can get away with sometimes even just emollient but often with low strength topical corticosteroids and we're using them for a short period of time, so I have no concerns about safety and families shouldn't either. That's easy.

When we start to get into those who have more severe disease, then we have to start thinking about mid strength topical corticosteroids, sometimes potent topical corticosteroids. And in cases where it's not just a flare that you can get under control in a few days or a week, even though it may be moderate in nature, but rather have either persistent or intermittent disease that you can get under control but in a short period after stopping medications comes back, then we have to think about the concept of maintenance and what would be safe as a maintenance regimen yet also effective.

I would stress that there's no one answer because every single individual with atopic dermatitis is an individual with different responses. And beyond that, the same person may respond well one day and maybe not in the next because of environmental factors and triggers and just how they got out of bed that morning. It's so highly variable. So, we need to be having a broad range and we need to be educating our patients about, “If this, that. If not, if this, that,” and just having the third option too so that there's a real understanding. I often tell my families the art is in the maintenance and you're going to have to be the artist who understands what equipment you have to work with and creates the palette. And it's so true, particularly with kids. The parents have to manage it in a way that they are comfortable in creating variations on the theme that address both safety and effectiveness for that particular child. So we may start with topical steroids using let's say a medium to potent topical corticosteroids and we may be able to get things under control in a one- or two-week period and then dial down to what's called proactive management where three times a week or even twice a week the family is able to apply to those areas that would recurrently flare without this continued pressure to use a topical steroid or a topical anti-inflammatory agent.

So, going down to two to three times a week on those areas that recurrently would flare and just continuing with that, unless the flare occurs that transiently would require going to more frequent use. This proactive approach has been shown to overall use less of the topical and yet maintain a more even keel in terms of control. But it doesn't work for everybody. I should say that this proactive management has been not just with topical steroids but in proven experiments has been shown to work with topical tacrolimus and hopefully over time and certainly for that individual patient you can get experience with others in terms of how does this work in a proactive regimen for you. So, for those in whom the proactive approach doesn't work — maybe the lesions are just jumping from this place to that place and there aren’t certain areas that you can try to just treat — maybe the situation is that you just can't get enough control when you're only treating two or three times weekly. Then we have to find some way to keep things under control on a more regular basis. And that may be done fairly safely by using steroids for flares and then maybe even using them two or three times a week but in between or otherwise in substitution that may be through using a calcineurin inhibitor or a phosphodiesterase-4 inhibitor or a topical JAK or new ones as they come out. But the art is in finding that agent that can be used safely for a long term in those individuals who do require continued topical therapy. If you cannot manage topically or I would say nowadays that we have such safe agents, if you have to be using a medium strength or stronger topical steroid at least daily to stay under control, which is not only just the burden of concern about thinning of the skin or other potential therapies from the topical use of steroids chronically but also the burden of having to put this on sometimes large body surface areas on a daily or twice-daily basis, then it's time to think about using a systemic agent or phototherapy.

Now I always have a checklist, an algorithm that I go through in my head. Is it truly an issue of not responding or is there an adherence issue where the family's not putting on the medication or not putting it on appropriately? And then we need to explore what the issues are and whether we can do it in a better way that actually works and works well. It could be that we're missing something. Is the child infected? And until we treat the infection, we cannot get the eczema under control. Is there something else going on? Could there be contact dermatitis where topicals are being applied and we think it looks like atopic dermatitis that's not responding, but it's really a secondary or unrelated contact allergic dermatitis? Is there something else going on? An entirely different diagnosis? The scabies that the rest of the family has, it continues to exacerbate the atopic dermatitis, as an example. So, we have to go through that process to think about what is the next step, but assuming that there's good adherence, that all of these others had been considered and ruled out and that it’s just a problem with not responding. We might think about phototherapy, of course that can't be used if somebody is very red and flared. And it does take a time commitment because often that involves having to go to a dermatology office two or three times a week for long periods of time for treatment. But if that's not feasible, or for certainly actually in my experience the majority of patients, we move on to a systemic medication.

Now we used to have just immunosuppressants and then it really was a hard ask of a family to go to a medication where there could be long-term risks if not short-term risks and required laboratory monitoring on a frequent basis. So, our threshold in the past I think has been a little bit higher than it is now. But now with dupilumab (Dupixent; Sanofi Genzyme/Regeneron) and others coming out we know that we don't even need laboratory monitoring. We can actually get it started and see good improvement in just a few months and then ideally continued thereafter. That will allow us to treat in a manner that is good if not better than what we were seeing with the systemic immunosuppressants.

So dupilumab has really revolutionized the care of our pediatric patients with atopic dermatitis. And on top of that, now we'll have others as well as the JAK inhibitors to consider for those who don't have an adequate response. But I would say my experience has been that most patients do have a response that is very meaningful to them and that the biggest issue is just the injection. Nobody likes to get a shot. Even adults don't like to get or give themselves shots. And so for a young child that becomes something that is stressful, that can strain the relationship with parents and parents might not like doing it and yet for most families it's OK because it makes such a difference in their lives. … A young child for example doesn't understand that, the parents understand that and, for most, can actually get that accomplished. We'll look forward to the day when there are other oral medications that are very safe but that will be a while to come.