Treatment Approach to Atopic Dermatitis

Linda Stein Gold, MD: Aaron, Matt talked about this whole new world of atopic dermatitis choices. Can you explain to us, how has that changed your practice in terms of treating your patients with atopic dermatitis?

Aaron S. Farberg, MD: Absolutely. He did a great job explaining all the tools we now have in our doctor’s toolbox. That is exactly what we’ve been needing. We’ve been desperate for all these options for so many years. Even before I started medical school, you think back to that, the ice age, what were the treatment options? It was just topical steroids, and now it’s not just 1 biologic agent. We have multiple, we have a variety of different JAK inhibitors as well to treat atopic dermatitis. We can treat the full spectrum of the disease as well. As Alexandra was mentioning, being able to identify what is mild, moderate, and severe atopic dermatitis is also important, and it’s not just skin deep. Even the normal skin isn’t quite normal, and the overall impact this is having on our patients is quite dramatic. So, having these options is important because we have a variety of different patients, and one may choose an injection, another may prefer a pill. Others will enjoy the topical options we have as well. Having a variety of options is absolutely key, it’s paramount to treating atopic dermatitis.

Linda Stein Gold, MD: You mentioned those patients who have more mild disease versus those who have more severe disease. We don’t want to forget those patients who might not be head to toe. It doesn’t mean just because you’re not at 100% BSA [body surface area] that this is not a significant problem for you. We want to make sure everybody is treated fairly.

Aaron S. Farberg, MD: It’s part of my general intake for all patients, skin sensitivity. A lot of patients don’t even recognize what eczema is or atopic dermatitis. The understanding of our general population, of our patients, not everyone even knows what to call it. They’ll just come in and say, “I’m itchy.” That’s where it’s our job to explore these symptoms and understand what is going on with these patients. Because hopefully, it is something as straightforward as eczema, although it’s obviously much more complex than that. But that’s also why it’s important to come see a dermatologist, a board-certified dermatologist, to evaluate your skin.

Matthew Zirwas, MD: Linda, can I jump in on something there? One of the things I often deal with whenever I’m out talking to my colleagues is that many dermatology providers don’t really understand, and I put it in a very specific way—what we are allowed to call atopic dermatitis. There’s now this concept in the literature of the atopic spectrum disorder that was published, I think Peter was of the authors on that article. It made me start thinking in terms of diagnostic criteria. When you look at the American Academy of Dermatology consensus criteria for atopic dermatitis, the essential features if it’s spongiotic dermatitis: it’s itchy, it’s chronic, and it spares the groin and axilla. If it has those 4 characteristics, you can call it atopic dermatitis. We’re still clinicians; we need to think, could this be contact dermatitis? Could this be scabies, could this be CTCL [cutaneous T-cell lymphoma], could this be psoriasis?

You have to clinically think through those other things, but when we talk about the toolbox, if we look at somebody and say, that’s nummular eczema, your toolbox now consists of topical steroids, methotrexate, cyclosporine, and phototherapy. If we look at them and say, that’s eczema, or that’s dermatitis unspecified, you have a very small toolbox. If we look at them and say, “You didn’t have it as a kid, you don’t really have atopic comorbidities, but it’s itchy, chronic, and spares the groin and axilla.” This meets the criteria for atopic dermatitis. Now you have a much bigger toolbox. You still can use topical steroids and methotrexate and cyclosporine, but now you also open up the rest of that toolbox.

Transcript edited for clarity