Treatment Options for Patients With Moderate Disease Over 10%-20% BSA

Raj Chovatiya, MD, PhD: To go along with that, Peter, for folks who are in that zone, they’re kind of better but not totally better, and they have something in that 10% to 20% body surface area range of involvement, maybe they started off with much more, and they are in that moderate range. Tell me about what treatments in general you’re thinking about for that in between patient?

Peter A. Lio, MD: I feel like that’s my specialty, betwixt and between, where they’re stuck. One thing I’ve found that has been transformative for my practice is a relatively new tool called the Atopic Dermatitis Control Tool, or ADCT. It was recently endorsed by the HOME group, Harmonising Outcome Measures for Eczema. It’s 6 questions, it takes 45 seconds to ask, and what it’s taught me is that a lot of patients who seem to be on the border are not, they’re actually really bad. A few times people are like, “I think I’m OK,” this and that. Then we go through the questions, and they have a really high score, and they start crying. And they’re like, “OK, I guess I’m not so good,” because I think it captures a bit more of what’s going on.

But in general, if someone is in that liminal state, I think we need to reassess everything, and we have to go from soup to nuts, start with the basics again. Are we still doing all the very basic things, such as gentle bathing, good moisturization, avoiding unknown triggers? Have we made sure that there’s not a secondary component, because sometimes people have a concomitant infection, usually a staph infection. I even had a patient just a few weeks ago who had what I think was a more chronic eczema herpeticum. She kept getting all these crusted papules, we tried a bunch of antibiotics, and it didn’t get better. Finally, I swabbed one, and it was HSV [herpes simplex virus] positive, and we put her on acyclovir, and that knocked it out. And of course, the contact dermatitis piece is a huge issue.

Once we get rid of all those, if those are playing a role, then I think those patients sometimes need to do extra care. We have to add something, so if they’re already on a systemic agent, maybe we’d add another low-dose systemic agent. For example, dupilumab plus low-dose methotrexate, or plus low-dose cyclosporine. I’m a big fan of phototherapy, and sometimes people, even if they failed it on the way up, now it could be OK on the other side. They may be doing much better on dupilumab, or on tralokinumab, and then we can add phototherapy back along with it. For some patients, it may mean just saying we’re going to stop what you’re doing and go up to something bigger, like an oral JAK inhibitor. But I find you really have to look at the individual, and these are hard patients because they can sometimes have more than 1 of these things happening at the same time.

Transcript edited for clarity