Assessing Severity of Atopic Dermatitis

Linda Stein Gold, MD: Peter, you have a very specific way that you try to assess these patients and figure out if we’re doing the right job for them.

Peter A. Lio, MD: Yes, and I think it’s come up beautifully already in a few different ways. Just looking at the patient, that has meaning, we have to still look, but it’s not the whole story because of this waxing and waning pattern. I often call it the mechanics problem. How many patients come in that day and say, “I know I look good today. But the last few months have been terrible.” A couple of issues with a point estimation; first of all, it is only that point in time. We want to try to expand the temporality of it. The second piece is the burden of disease, as Aaron talked about as well. How do we assess that? I think the severity of atopic dermatitis starts to ring hollow in my mind too. What does it mean to be severe? Then you treat somebody and they come back, well, are they not severe now? They’re better today. All of these things start to sound kind of moot in your mind. What I like now is to think about their control. Matt brought it up in a very direct way, just to say, “Are you good with your eczema?“

There is a structured tool called the Atopic Dermatitis Control Tool, or ADCT. And it is brilliant. It is 6 questions, it takes 45 seconds to go through. Since I’ve started doing it, it has revolutionized my whole practice. You ask these questions, each one begins with, “Over the past week,” so you get that temporality. And they’re asking these hard questions about how the patient’s dealing with it, how they’re feeling, how they’re sleeping. I find that patients who come in maybe at first seeming pretty positive, “I think I’m OK,” when we go through these questions it’s sort of the dermatologic equivalent of discovering Gobekli Tepe, the archaeological site that changed everything. Because now they say, “Wait a minute, now I have a point in time, and I’m not so good.” At the end of those visits, sometimes they’re a bit shaken, sometimes they’re crying. I say, “But this is good because now I know that you’re not under control. We thought you were under control, but now we see you’re not.” And that will allow me then to extend treatment to get them to that point where they’re under control.

Linda Stein Gold, MD: And the problem is, just as you say, we see a snapshot. You have a beautiful tool that you use. One of my simplest tools is I simply say to the patient, “When was the last time your skin was completely clear?” And for some patients it’s, “I’m coming in today because I just used something, some fragrance, cream, and I just broke out and I’m terrible. The last time I was clear was 2 weeks ago.” For other patients, they look at me like, “I don’t even understand the question. What does that really mean? What do you mean clear? When I was 3, I don’t know.”

I think trying to assess, again, we have such a short period of time, and [we’re all] trying to understand. We probably all assess a bit differently. I love the fact that you delve in, and what you see today is not necessarily representative. Sometimes we see patients on a great day, sometimes we see them on a terrible day. The other issue too is, in psoriasis, we’ve moved away from the mild, moderate, and severe. We more categorize by, can I control you with topical therapy alone or are you a systemic candidate?

Aaron, what do you do? Do you look at them that way? How do you gauge?

Aaron S. Farberg, MD: That is a very important point. For me, it comes down to the patient. Every patient, I tell them about all the options. Mostly because where I trained in New York, a lot of patients love to use Dr Google. I know they’re going to look up a variety of different treatment options. I don’t want to be that doctor who didn’t discuss all the options. So, even in my mild patients, I’m discussing the JAK inhibitors, I’m discussing the biologic options as well.

Then we have a collaborative discussion with the patient. Now, here’s all the different options. We understand your burden of the disease. Which therapeutic option is going to be best for you? The great part is all these options are generally very safe, very efficacious. And so, selecting the right one and personalizing it for that patient, it’s not an easy task, but it’s most definitely performed in a collaborative method. This way, it’s ultimately up to the patient.

Alexandra Golant, MD: If I can jump in for a second, I think when our systemic agents first came out, as in so many diseases, we were using them for our moderate but skewing severe patients. What we’ve seen is this recommendation to move away from these boxes of mild, moderate, and severe. Yes, you can reach that moderate to severe category by reaching a 10% body surface area or an IGA [Investigator’s Global Assessment score] 3 or 4. But we know, as all of us have echoed, that we see these patients one day at a time. Sometimes you catch someone on a good day.

I make the majority of my decisions based on quality-of-life impact. I think using that as your guiding light to define who is well controlled with a good topical regimen, and who is not? The 10% [body surface area] or more is really an insurance requirement more than it is a practical requirement. Oftentimes, especially for your adult patients, you’re dealing with a population of individuals that have lived this disease every day since the age of 2 or 3. I find patients often underestimate their own disease severity because they’re not as bad as they were on their worst day of their life. For them, it’s OK. They can honestly not always imagine what life is like without that chronic itch.

That’s why I think sharing all of the treatment options, even to a patient who on that day and time looks mild, is so important. The ADCT is something I’ve stolen from Peter, and I’ve started to incorporate in my own practice. And especially for those patients who are a little slower to warm up, or don’t just come in open book to your exam room on that first visit, it has been an incredibly helpful tool to parse out what is the real day-to-day like for them.

Linda Stein Gold, MD: I think we have an obligation as dermatologists to truly understand every treatment option, because if we ourselves are not comfortable with the options, that significantly limits what we offer to our patients. I feel that it’s our job to understand each one of these drugs in depth, understand the efficacy, understand the safety, understand what we can expect.

Transcript edited for clarity