Treatment Goals and Challenges for Atopic Dermatitis Management

Linda Stein Gold, MD: Ale, I want to turn to you. When a patient comes in, do you talk to them up-front about what their goals are, and how do you set those goals? Does it differ depending on the age of the patient?

Alexandra Golant, MD: Yeah. Goal setting is important, and asking patients what does ‘ideal’ look like for them? The answers are sometimes different. You can see a patient with full-body eczema who will just tell you, “If I could just get rid of my itch, I don't care how my skin looks.” Obviously, ideally, we'll target both, but you get a sense of what is driving their suffering. For most patients, my personal goal for them is to allow them to get to a point where they're living their life as if they don't have this chronic disease—like without their atopic dermatitis. I say, “This is going to be with you for your life, but it doesn't have to control your life or control the narrative of your life.” Like Eric was alluding to, if they're willing to use topicals, do they never want to see a tube appointment again? What would be their happy place in that mix? In terms of the age of the patient, I don't find that the goal-setting differs that much, although for younger patients, the goals are being set by our parents and caregivers. As Raj had mentioned, understanding how the disease is impacting the family unit is important—not just parents, but siblings and the whole family dynamic because it does trickle into every crevice of life. Getting a sense of how you can intervene and minimize the family's suffering is important too. That all plays into how aggressively and how quickly you escalate up-treatment ladders and things like this.

Linda Stein Gold, MD: Yeah. I agree with this whole conversation. In psoriasis, we have a target to treat. In atopic dermatitis, my goal generally is that if you ask somebody who has a moderate-to-severe disease, “How often do you think about your skin?” They look at you like you're a crazy person. Like, “I'm always thinking about my skin.” My goal is always to take it from right here and put it back here: “I don't live my life around my atopic dermatitis, but I am somebody who happens to have it,” so that is my goal is always. When I say, “How often do you think about your skin?” and they go, “Oh, right. You know? Yeah. Not so much.” Then I know we're really there. But Raj, I know that as physicians, we come up against a lot of challenges and certain limitations. Can you address what you think the common ones are and how you try to handle them?

Raj Chovatiya, MD, PhD: Sure. What my colleagues have beautifully discussed is everything that goes behind shared decision-making, like this concept of working with the patient to try to address what's important to them and what's important to you and come to a happy medium. When I think about treatment choices for adolescents and adults, people largely are interested in any one of these things. A treatment that works, something that's going to work quickly, something that's going to keep working, something that they feel safe about, something that has improvement of their skin and their symptoms, something that they can actually get their hands on, and a category that we haven't paid enough attention to: something that's feasible, something that they're actually going to be able to do, and something they can actually afford and make it a part of their day-to-day plan. It's really important in the back of your mind to be thinking about those categories when you're talking about treatment options with your patients, and not everybody values the same ones nor do they have the response to the same ones. For somebody, they may want something that works quickly that may not matter to someone else. For someone, cost may be a big issue. That may not matter to someone else as well. That's the really individualized therapeutic plan that comes with working on trying to find the best plan forward for our patients with atopic dermatitis.

Linda Stein Gold, MD: Eric talked about the difference between the systemics, the orals, and the topicals. Do you ask your patient upfront, “Do you want a topical or do you want an oral?” Because I know sometimes we'll go through a whole long decision-making process and we'll prescribe something systemic; and then you realize, no, they're not going to take anything systemic. They're just not going to go there. Do you address that up-front and try to weed that out?

Raj Chovatiya, MD, PhD: Yeah. I like to think of it kind of like that scene of the matrix, where you have 2 hands and you're like, red pill or blue pill? I like to make sure that they understand that we have choices and each of those choices has both strengths and negatives when it comes to the severity of their disease, both in terms of signs and symptoms and what they value. I never would've believed this when I started out training: you put it in the patient's hands, they largely start to lead you towards what they want to do as long as you give them the chance to add their opinion. That is very powerful. At the end of the day, me forcing someone to do a systemic therapy that I know that they're not going to follow through—it's not a good therapy because they're just not going to do it. I'd rather that they have a topical that they use well, even if they're not clear by my standards that I've set in my mind rather than something that they may intermittently use or just not come back and see me anymore.

Linda Stein Gold, MD That's interesting. I'm going to come back to you, Eric. When you're talking about the treatment choices, do you look at your patients and say, “I see you and I see your disease. This is what I recommend based on your severity, your age, and everything else.” Or do you provide them with a menu of options and let them choose? It's interesting because people approach this shared decision-making a little bit differently, so I'm kind of interested in each of your approaches. Do you say, “This is what I suggest? Or do you give them a menu?

Eric Simpson, MD, MCR: Raj went over that well. I'll just add a little bit to that. Patients approach that, maybe providers do, but also patients do. Some of my older patients want me to be more paternalistic and my younger patients do not. My older patients get disappointed in me because I keep trying to put the decision-making on them, and so sometimes you have to be paternalistic, but I prefer an equal kind of shared decision-making process. No, I don't necessarily choose for them, and I wouldn't give them options that I think are not appropriate given their medical condition or their severity. I try to tailor my choices for them based on my medical expertise. Then, if I feel like there are just fine choices with the slight trade-offs of safety and efficacy, I put that into their court and see. I can't remember who said it, but if you know their preferences early on in terms of risk aversion or other things, that just helps move the conversation forward and get to a spot where they can make an informed choice.

Linda Stein Gold, MD: I agree with you. Ale, do you feel like there's a difference too, depending on the age of the patient? Some want, “You're the doctor, so you should tell me.” Others say, “You know what? Let me understand the whole menu—the whole situation—and let's figure this out together.”

Alexandra Golant, MD: I practice in Manhattan, where people sometimes come having done a lot of their own research and have strong opinions on treatment that they've read about. Patients know themselves the best, and I really stand by that. One thing that can be helpful in talking to patients—especially these individuals who have had atopic dermatitis since childhood and see you decades later into their disease journey—is labeling. There are topical patients and then systemic eligible patients, but the way that the [United States Food and Drug Administration] FDA labels these treatments, it's this moderate-to-severe category. For patients that fit into that bucket in my mind, I do think that there is some power in telling patients, “I view you as a moderate-to-severe patient, or in my opinion, you have pretty severe disease. I want you to know I'm taking this seriously, and let me tell you about treatments that did not exist 5 years ago. If you want your outcome to be different, we can get you there.” Many patients approach the conversation a little bit jaded because they were only given and cycled through topicals for so long. As much as I want to move away from these kind of very inorganic, mild, moderate to severe, I think there is some power in labeling patients and telling them, you are basically a topical patient or a systemic-eligible patient, and this is why.

Linda Stein Gold, MD: I agree with you. For some of our patients who are on the borderline, we have some newer agents now, whereas I might not have thought that I could get them under control with the topical. This is a new world and now, we have to try again.

Transcript Edited for Clarity