Latest News

Advising patients on AD treatment options: Expert pearls


 

AT RAD 2023

What does shared decision-making about atopic dermatitis (AD) treatment mean at a time of increasing treatment options and patient concerns about drug safety and the potentially lifelong need for systemic treatment?

The question was top of mind for experts who shared their advice during a “Tips and Tricks” session at the Revolutionizing Atopic Dermatitis meeting. Dupilumab dosing and dupilumab-associated facial redness and ocular disease, self-image issues, topical regimen adherence, and the quantification of disease were among the other topics raised by the experts.

Here are some of their practice pearls.

Treatment decisions, safety concerns

Deciding on a treatment is “kind of confusing ... particularly in the last year ... and it will only get more complicated,” said Raj J. Chovatiya, MD, PhD, assistant professor of dermatology at Northwestern University, Chicago. “We’re all about some version of shared decision-making, but if all else is equal, sometimes it pays to explicitly ask the patient, what do you want to do?”

Dr. Raj Chovatiya, department of dermatology, Northwestern University, Chicago

Dr. Raj Chovatiya

Questions about how long a systemic treatment should be tried, both initially and in the long run, are common. “I think that oftentimes we all get antsy about making changes when we’re not getting to the endpoint we want to. And at least in my real-world experience, late responders are a real thing. Sometimes 3-4 months ... isn’t enough,” he said.

Trial extension data show that patients who were nonresponders for various endpoints at 16 weeks are “captured continuously as you go further and further out,” Dr. Chovatiya said. Regarding the long term, “realistically, there’s no perfect time to call it quits.”

Addressing fears about Janus kinase inhibitors can be challenging, he said. “When you’ve identified the right patient and labs are done ... have them take the medication in front of you and hang out,” he advised. “It may sound ridiculous, but for the extremely anxious person it can be a big stress reducer for everyone involved.”

Regarding treatment fears more generally, “asking patients ‘what is the biggest risk of not treating your disease?’ sometimes gets people thinking,” Dr. Chovatiya said.

Dr. Robert Sidbury, division chief of dermatology at Seattle Children's

Dr. Robert Sidbury

For parents of children with AD, said Robert Sidbury, MD, MPH, risks of not treating can become apparent once treatments are started and benefits are realized. “It’s so easy to focus on the risks of any treatment because they’re right there in black and white, and the risks of not treating are not always as apparent, even though – or maybe because – they live with them every day.”

When treatment is underway, “they see [how] everyone sleeps better, how school performance gets better, how concentration gets better,” said Dr. Sidbury, professor in the department of pediatrics at the University of Washington. Seattle, and chief of dermatology at Seattle Children’s Hospital.

“Always contextualize,” he advised. “As dermatologists, we’re savvy with navigating boxed warnings.”

David Rosmarin, MD, vice chair of research and education, Department of Dermatology, Tufts Medical Center, Boston

Dr. David Rosmarin

David Rosmarin, MD, chair of dermatology, at Indiana University, Indianapolis, and formerly vice chair for research and education at Tufts Medical Center, Boston, said he addresses questions about the length of systemic treatment by advising patients: “Why don’t we start taking [the medication] for 3 months and then we’ll take it from there.”

In some pediatric cases, Dr. Rosmarin said, having the child express “what their AD means to them – how it affects them,” and then acknowledging and validating what the child says, is helpful to parents who are concerned about systemic treatments.

Pages

Recommended Reading

Meta-analysis shows unidirectional association between atopic dermatitis and rheumatoid arthritis
MDedge Dermatology
Low diversity in skin microbiome in infancy raises risk for atopic dermatitis in high-risk children
MDedge Dermatology
Single-strain probiotic lactobacilli: An up-and-coming adjuvant therapy for atopic dermatitis
MDedge Dermatology
AD in infancy: Diagnostic advice and treatment tips
MDedge Dermatology
Can online mindfulness and self-compassion training improve quality of life for patients with atopic dermatitis?
MDedge Dermatology
JAK-inhibitor safety in adolescents with AD: Long-term analyses reported
MDedge Dermatology
Commentary: AD, RA, Probiotics, and a New JAK inhibitor, June 2023
MDedge Dermatology
Enthesitis, arthritis, tenosynovitis linked to dupilumab use for atopic dermatitis
MDedge Dermatology
Dupilumab outcomes stable at end of open label atopic dermatitis study
MDedge Dermatology
Abrocitinib remains effective at 96 weeks, in older as well as younger adults
MDedge Dermatology