Atopic Dermatitis: Treatment Selection

Melodie Young, MSN, RN, ANP-C: We talked about pediatrics that the drug came into the marketplace as an 18-and-over for moderate to severe atopic dermatitis [AD]. Douglas mentioned about adult-onset AD. I’ve seen a surprisingly large number of patients who end up coming through our clinic have AD as an adult. Susan, do you see that happening? I feel like I have more folks who had it throughout their lives, and I know you can get adult-onset asthma, so it makes sense that we would see an adult-onset atopic dermatitis as well. I know the work-up may be a little different, but are you seeing that?

Susan Tofte, DNP, MS, FNP-C: I see that too. As Douglas said, it’s not nearly as common as seeing it in childhood, but occasionally I’ll get a patient and they say, “Oh, no. I started this at age 20. I didn’t have it before that.” I know my esteemed colleague who’s now a professor emeritus, Dr [Jon] Hanifin, always would probe those patients there. “You should go ask your mom or dad, if you had eczema when you were a baby,” and they wouldn’t remember that. He’s convinced that there’s some early onset, but even he would admit that there would be that rare patient who will present it in adulthood. You do want to rule out other things because we had a patient who had this adult onset, and it turned out that he had CTCL, cutaneous T-cell lymphoma, which had been misdiagnosed as eczema atopic dermatitis for a long time. If it’s an adult onset, you want to be sure you’re certain of the diagnosis.

Melodie Young, MSN, RN, ANP-C: When do you decide that it’s time to prescribe or what you’re going to prescribe that patient? Do you think, “Let’s try topicals and you have to fail it?” Or “You have to try phototherapy and you have to fail it.” Or do you just start right off the bat when you see patients and say, “This is what you’re going have to have. We have to put you on dupilumab.” Douglas, what’s your approach to making the decisions? If you’re trying to coach someone who’s just coming into dermatology as a nurse practitioner or a physician assistant, what advice would you give them?

Douglas DiRuggiero, DMSc, PA-C: There’s not a straight answer to that. It depends on the age of the patient. It depends on how much body surface area or severity is there. We’d all agree for mild patients with limited body surface area, particularly if it’s nonsensitive areas or non-life-altering areas, that topicals is the way to start and to go, depending on the mildness. You may start with a superhigh potent steroid for a short time, then move them over to 1 of the TCIs [topical calcineurin inhibitors]. Susan discussed very succinctly, when you move into the category of moderate to severe: it’s a different beast, and some of it’s the history. They’ve come in already on 3 and 4 topicals and oral Prednisone, so I’m already moving them toward these therapies right off the bat. If they come in naïve and there’s still a monitor sphere, I’m already talking to them about the fact that I want to introduce this idea of being on a systemic therapy, a new treatment, just to get a feel for their comfort level. I have no problem starting something like dupilumab on the first visit. If the severity of the disease, the chronicity of the disease, or the life-altering quality-of-life issues is there, that would justify it.

Remember, it’s indicated for moderate to severe. If they’ve got that right and they’re following the indications then, because I know this is systemic, I know that this thing is always smoldering waiting, it might explain to them that pathophysiology and the ease of mind they can have, and then they begin to open themselves up to this type of treatment. When an adult presents, even if they had a history of it, I never want to assume it’s atopic dermatitis that’s gone through a 10-year period where it disappeared and has come back. I’m always going to ask them about any chemicals they put on their skin, what their occupation is, what makes this nonallergic or an irritant component to this, would they need patch testing or allergy testing, and do we need a biopsy to make sure that’s not something like cutaneous T-cell lymphoma, or just a number of other disorders that can present. Even some forms of lupus can have an itch that you can lichenify and PMLE [polymorphous light eruption]. We all have these differential diagnoses that I think we need to consider on the adult side. We need to look at age, the severity of disease, previous treatments, and quality-of-life issues. Those are the 4 categories that I can ask very quickly about, assess, and suggest options to help them make the decision that’s best for them, rather than dictating what they have to do if they want to be better.

Melodie Young, MSN, RN, ANP-C: It’s part of the art of what we do. There’s a lot of scientific evidence to the diagnostic process when Susan mentioned Dr Hanifin and the Hanifin criteria to try to help diagnose. Sometimes we see patients who’ve had it for so long, especially in the non-Caucasian, and their skin is so lichenified, or they’ve scratched it so much that people will say it’s a different disease. But really, it is just AD that’s been there for far too long.

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