Korey Capozza, MPH

 I know it’s a loaded question, but what are the biggest challenges you face when it comes to managing patients with atopic dermatitis?

 One is access and insurance frustrations, which can wear on you as a physician. All you’re trying to do is do the best for the patient, and you feel as if there are roadblocks in your way. Sometimes going through the prior off struggle, it’s like jumping over hurdles. But every time you jump over a hurdle, somebody says, “Wait, did you fail pimecrolimus [Elidel] first”? Can I jump this hurdle, please? Every hurdle is more than the hurdle. It’s questions and paperwork and all that stuff. Access is a big deal. The other thing is there’s a lot of misinformation out there. Programs like this with participants like this are excellent resources for patients with atopic dermatitis who are struggling. But there’s a lot of stuff out there on the internet that isn’t exactly the information I want my patients perusing and following. Sometimes I’m combating that during my clinic visits as well.

 You highlighted a couple of big challenges. I’ll take a forward-facing view. In my estimation, 1 of the big challenges when it comes to medications—let’s say in new treatments—is that atopic dermatitis sometimes feels like it’s a bunch of different conditions under this umbrella. Patients present so differently and have different constellations of signs and symptoms. Their comorbidities are totally different. It’s 1 reasons why having 1 or 2 treatments isn’t enough. We’re not at a point where we can say this is going to work for everybody without any exceptions. We’ll probably never get to that point because of the way that atopic dermatitis works. We definitely need to continue looking into new mechanisms of actions for new therapies.

As far as unmet needs go, evolution in the topical space has largely been limited until recently. We’ve had topical corticosteroids and topical calcineurin inhibitors, but at a certain point, everyone said, “That’s enough. We’re done. We don’t need any more.” Until essentially the approval of crisaborole a few years ago on topical ruxolitinib, there wasn’t much happening, but now there is a lot of stuff that’s far in the pipeline. A new topical PDE4 inhibitor roflumilast looks to be more potent than the previous predecessor crisaborole that also has good application site. Not much reactivity for patients. Topical tapinarof is another 1, a new class of medications with a new mechanism based on returning the skin to homeostasis. That’s just to highlight a couple.

Even on the systemic side, we have new oral therapies. We talked about the JAK inhibitor class. There are new targets being looked at for biologic therapy, and there’s more specific targeting of interleukin 13, another pathway called OX40 ligand, and a variety of others that are probably going to be coming to a toolbox near us. The more choices we have, we can hopefully get to that point of saying, “This is what somebody’s signs, symptoms, comorbidities look like at baseline. This is the best treatment I’m going to match up with.” That’s the Holy Grail for what we want in the dermatology community. Hopefully we’re going to get to that point. We’re a lot closer than we were before, so the treatment landscape is going to continue evolving. As I mentioned before, it’s not an exaggeration to say that we’re beyond 100 in terms of everything across various phases of trials. If anyone ever to the registered database for clinical trials, you’ll see there’s a ton going on for atopic dermatitis.

One big area that I’ll leave on, where I want to see more work done, is that when there are differences in racial and ethnic background, geography, patients with skin of color vs not, how does all this figure into No. 1, appropriate diagnosis and estimation severity, and No. 2, the best and most effective and safe treatment. Even with certain conventional treatments, there’s an undue burden placed on patients with skin of color. I’ll highlight topical corticosteroids as 1 of those. Chronic use of topical corticosteroids is associated with dyspigmentation. It’s a problem that I’ve had with my patients with skin of color. I’m sure Lisa has seen it in hers as well. We need other options from that simplistic standpoint, but even when you break it down in terms of differences in biology and presentation, there probably are different aspects of the disease that are going to need to be researched.

That’s how I see a few of those challenges from a treatment and patient-identification perspective. This awesome panel highlighted issues when it comes to actual access of medication, advocacy, building that community, what it like to go on that journey: from the patient and caregiver side and from the medical side. From that point, I’m going to close. A big thank-you for everyone for watching this 

®. If you enjoyed the program, please subscribe to our e-newsletters to receive upcoming programs and other great content right in your in-box. With that, a big thank-you.

Videos

Elizabeth A. Swanson, MD, and Raj. J. Chovatiya, MD, PhD, examine challenges in managing atopic dermatitis and explore the evolving treatment landscape.

Unmet Needs in Managing Atopic Dermatitis

Let’s transition and talk a bit about Taylor and Tina. I’ll start with you, Taylor. Do you have any pearls, tidbits of advice, that you would pass on to somebody if they were watching this or you were talking to another family member or friend if they were diagnosed with atopic dermatitis and had similar symptoms? What would you want them to know in terms of high-level points?

 One thing that Korey said that resonated with me is that you have to self-advocate but also find the partnership and the doctor and not settle for anything less than that. That was 1 of the biggest struggles. Granted there weren’t as many therapies on the market as there are today. It wasn’t until I found the right doctor. I always joke with my parents. I moved 12 hours away from them to Chicago to pursue a job, but I always joke that I was destined to be here to No. 1, find my dermatologist, and then No. 2, find a fiancé. I joke with them all the time about that because it’s such a game changer, finding a medical professional who’s willing to advocate and spend the hours and the time it takes to make sure you’re getting the treatment.

I remember going through health care approvals. To your point, it was like you need to use this cream and to have taken this step. I did all that, but they still wanted me to document it and try it again before they would get me to dupilumab. My advice is No. 1, definitely educate yourself on what your options are. But No. 2 is key: don’t settle for a doctor who’s not willing to fight for what’s best for you. Go up against the insurance company. There are so many programs out there that will give you access to the medication if it’s something you don’t qualify for or if it’s too expensive. There are many programs out there that will help supplement the costs.

 You highlighted 1 powerful element. Oftentimes, if you’ve lived in 1 place or another and you’ve seen multiple providers, your health care provider isn’t going to know your history and treatment journey as well as you are. Something I recommend to all my patients is keep track of what you tried because you may have tried many things. If you got a good list of it, that’s exactly what’s going in my documentation. If anybody on the other end tries to tell me you have a jump through these hoops, that’s nonsense because we’ve done this and we’re not doing it again. We’re not settling for that. That’s a powerful piece and something to hang on to from the patient aspect.

I’ll flip it to Tina. What would you have done differently if you were to go back in time with Taylor to when she was younger?

I would have been more persistent and pushed the envelope a bit and tried to get the doctors to not just treat the topical but to look at the root cause of what was going on internally that was causing the atopic dermatitis and the symptoms she was experiencing. That would be my thing. It’s more or less the root cause.

That’s powerful in the sense that we understand much more about the condition and have many more resources. It’s a reasonable ask for people to feel like they understand what’s going on with their body when it comes to atopic dermatitis in 2022. I’ll flip it to Korey. Is there any particular advice, any pearls that you have, for patients and their families when it comes to advocating for themselves, forming a community in terms of trying to get at support for atopic dermatitis?

Yes. Thanks for asking that question. This condition can be so lonely. The impacts are hidden from view, and even your closest friends and family struggle to understand it. We talked about the mental health impacts, the isolation. It’s important to connect with the community. Thankfully, there are a lot of ways to do that. Our organization [Global Parents for Eczema Research] has a support for eczema caregivers program that’s free. We have small groups going on almost every week where you can connect with other parents, so you don’t feel that sense of isolation, as though no one understands what’s going on. If you can connect with other families and other patients who understand that it’s such a relief, then it really is. It makes you feel as though you’re not crazy. You’re not the only 1 experiencing this. Sometimes it’s almost as if the people around you, when you’re dealing with moderate to severe eczema, think you’re exaggerating or being a drama queen. Something about it they can’t understand: all those impacts that are hidden. When you can connect with a community that understands, it’s incredibly liberating. It’s wonderful for patients and parents. Look for those. There are several organizations. You mentioned the National Eczema Association. Our organization can also offer that and encourage parents and patients to connect on social media and other ways to find community.

 That’s very helpful. If we flip the community aspect around to the medical community—Lisa, I’ll direct this to you. A variety of practitioners out there are going to be helpful when it comes to treating and managing atopic dermatitis. You have MDs [medical doctors] and DOs [doctors of osteopathic medicine]. There’s an important role that physician assistants [PAs] play. There’s a big important role that nurse practitioners [NPs] play. How does this medical team or health care team work together to try to get control of atopic dermatitis?

 That can certainly be a challenge. Some communities do it well. In other communities, it’s hard to have a synchronized force of people who are motivated and enthusiastic about treating atopic things. As a dermatologist in Colorado and in Idaho, I made sure that I found allergists in my community who were similar-minded. I felt that a patient wouldn’t get 2 completely different polarizing views of atopic dermatitis during each visit. I found a couple of pediatric gastroenterologists, because eosinophilic esophagitis is a huge issue for a lot of very atopic kids. If my allergists weren’t comfortable handling asthma, teaming up with a pulmonologist that could help me with that, so I knew whom to send my patients to. Maybe I was the ringleader, but I had this team of people that I created for myself, that I felt comfortable having my patients see and that I felt comfortable would communicate with me to make sure we were all on the same page. In the end, it boils down to the individual physician or NP or PA to form their circles to give the patient the best all-around care.

Korey Capozza, MPH; Elizabeth A. Swanson, MD; and Taylor Capps share pearls for patients and their families managing atopic dermatitis.

Key Takeaways for Atopic Dermatitis Management

: That allows us to segue beautifully into picking Korey’s brain a bit. Can you talk about your role as a patient advocate and consultant? Talk about some of the stuff you do to help patients and caregivers on this journey.

: Thank you. I love to hear everyone talking about the exciting time that we’re in with these new treatments because I feel the same way as you, Lisa Elizabeth. I see these children who have been on this journey with our organization for 5, 6, 7 years, and suddenly their whole life is transformed. Someone said you’re held captive by this condition, and that resonated with me because it’s like these patients are prisoner to their eczema. When it’s gone, the person they were meant to be comes out, and it’s amazing. It moves me to see these children who were hidden for so long suddenly become star soccer players, or into theater, or whatever it is. It’s like the life they were meant to have suddenly unfolds for them. It’s amazing to see, so we’re so lucky to have these new treatments. I also wanted to say it does pain me a bit to still see requirements that we put children with more severe eczema on these old school systemics before they can get dupilumab. Back in the day, maybe we didn’t know what was better, but we know now. Those are not safe treatments compared to dupilumab. That shouldn’t be a requirement anymore. I hope that changes, and certainly, groups like ours are working on that.

In terms of what patients can do to advocate, and what groups like ours do, there’s a lot. I’ll say to patients out there, find yourself a Dr Raj, find yourself a Dr Lisa, someone who’s going to fight for you, who’s going to get you the treatment you need, who’s your partner out there, and don’t settle for anything less. You need that if you have this condition. It’s hard to figure out on your own for the best of us. I often say, my degree is in public health, I have a background in research, my husband is a PhD researcher, and we couldn’t find something that worked for our son. We were looking at all the research and trying to find the triggers and associate those with our son’s symptoms. It’s hard, and you need a champion, so look for that and continue to fight for it. Don’t settle for less. Then I think you do feel burnout. The patients feel the burnout, the caregivers feel the burnout, especially among the adults, they’re burned out, but don’t give up. It’s a different era, and there are better options. So get back out there, and demand something better for yourself because you can have a different life than the one you’re having if your eczema is poorly controlled.

Those are just some immediate thoughts. Be an advocate for yourself, but find a partner who can do it with you. I think that’s the way to have the most success. Then you do have to be a detective with this condition, but you don’t have to be the detective by yourself. I think there are ways that health care professionals can help find those triggers, find those underlying things that might be causing the eczema.

: All of those are incredible points. In many ways, we’re lucky to be in a time where there’s so much information, and educational opportunity is accessible for our patients. But in many ways, it’s almost confusing because there’s so much out there. “What am I supposed to follow? What don’t I follow? The health care provider told me this, but he or she didn’t talk about that,” and whatnot. I agree that this whole concept of having someone who can quarterback that team and partner with you is vital because it’s hard to do it alone. One of the biggest challenges of atopic dermatitis is the disease is so heterogeneous that person to person, the entire case can be different, everything from the physical findings, to the burden, to the symptoms, to the treatment. We really don’t have that information. Maybe we will, where if I see you one time, you check these boxes, this is exactly how your atopic dermatitis is going to go over the next 10 to 20 years. Maybe we’ll get there, but until that point, this is the discussion that needs to happen.

Korey Capozza, MPH, highlights the importance of patient advocacy in the atopic dermatitis journey.

Patient Advocacy for Atopic Dermatitis

: We highlighted some of these barriers, but to review, and Lisa Elizabeth, you can jump in on ones I don’t mention. We talked about insurance reimbursement from the physician side, there’s a big problem. The overall amount of time and effort, it requires office staff, you, and everyone working with you to try to get things approved. From the patient side, it seems like a big black box, I have no idea what’s going on, what’s going to happen. But there are other barriers that maybe we don’t think about as much and that are less studied. I’ll highlight one that we’ve done some research on with the National Eczema Association, out of pocket costs are a huge one that we don’t tend to classically think about. When you look at the amount of things that our patients and caregivers are trying over the counter related to prescriptions, parking, child care, laboratory work, you name it, this adds up. This is another one of those ideas that we don’t tend to think about as much when we’re making a plan. It’s something I’ve started to be cognizant of how can I simplify what I’m doing, but also consider, OK, is this going to be a huge financial burden for our patients? From the medical side, Lisa, what are some of those other barriers that I may not have mentioned that you tend to think about?

: That out of pocket cost is a big one because so many people have high deductible insurance plans, where even when a particular drug or whatever is “covered,” that only means once you’ve paid your $5000 or $10,000, or whatever it is. And programs like for dupilumab [Dupixent], Dupixent MyWay, is very helpful for those situations. Most of our drug companies for these newer medicines do offer something like that. Those are vital to us being able to prescribe and get these therapies for our patients and their families. I am also always surprised at the cost of all the over-the-counter things that people have tried. I, too, will try to simplify things, you don’t need to be using all of these various different things, emu oil or whatever people find online. I try to say, “Hey, let’s focus our time, our energy, and your dollars on things that I think are going to be helpful for you and your child, or your teenager, or whatever it might be.”

: Yes, Tina, do you recall from your perspective, particularly when Taylor was young, some of the stuff that you ended up spending money on, or barriers you faced in getting therapies that worked? Can you take us through a bit of that time?

: Back in the day, we didn’t have access to as many of the dye-free products, a lot of those places. We’d have to seek things in specialty pharmacy stores. I had to have some of her creams compounded. From that standpoint, that would be a barrier, finding the products that were being recommended over the counter. Of course, we did have out of pocket costs associated with the prescription drugs and things like that. That would be the main thing, the barrier I faced was finding the products, a lot of the things recommended to me over the counter. It was then, going, searching, finding; we didn’t have access to Amazon, and all that stuff. It was a trial to seek out places, try to find it.

: Yes. Taylor, have you found any particular resources, support groups, education to be helpful on this journey, even before you knew what was going on, or after you figured out you had atopic dermatitis? What’s been helpful or useful for you?

: Going back to what my mom was saying, it’s the access you have today. It’s important for folks to educate themselves. Videos like this today are helpful things that we didn’t have access to. We call my mom WebMD, she’s always searching and Googling things. But if we would have had access to tools and the knowledge base available online today, I think I could have been able to find a solution faster. But the access wasn’t there. Today, it’s vital for you to be an advocate for yourself. That’s been one of the biggest things for me. When going to the doctor, I assume they’re going to tell me what’s wrong, and they’re going to be able to look at it, diagnose me, and we move on. But one of the biggest things is having to research it and go to your medical professionals with what you think could be the problem, or say, “Here’s what I found,” and have them try to validate those things.

What I’ve found is if you’re not advocating for yourself, oftentimes you’re left behind. It’s an unfortunate place the medical field is in, but they’re treating so many patients and have such limited time, that if you’re not doing that, it definitely is going to hinder where you go in the future. It’s been very frustrating to me. Something I’ve had to learn over time is that, the more education you have going into an appointment, the better off you are.

Raj J. Chovatiya, MD, PhD; Elizabeth A. Swanson, MD; Tina Capps; and Taylor Capps assess barriers in finding and obtaining atopic dermatitis treatments.

Barriers to Access for Atopic Dermatitis Therapies

: As Lisa told us, the last 5 years and counting have been a miraculous time for the case of atopic dermatitis, because years of research have started to pay off. Instead of treatments that are designed to do the best we can to limit inflammation, there are now more disease-modifying therapies, or particularly immunotherapies, that can work on the patients with moderate to severe disease. We heard about one of those in Taylor’s story, dupilumab, which is what we called a biologic therapy. Biologic therapies are injectable. They’re literally very specific antibodies that turn down overactive pathways in the case of inflammation. In the case of dupilumab, it’s a biologic that controls IL-4 [interleukin-4] and IL-13 [interleukin-13], which are 2 important signaling molecules in inflammation. There was another biologic that was recently approved, tralokinumab, this one’s more specific for one of those pathways, IL-13.

The advantage of these types of therapies is that they’re dosed every couple of weeks, safety is very promising, so no laboratory monitoring. There’s not immunosuppression going on, and they seem to provide longer term control to people who have bad moderate to severe disease. And so, particularly with the approval of dupilumab now 5 years ago, I can’t believe I’m saying that, it’s changed how we think about treating atopic dermatitis not only in adults but also adolescents and children. And based on some promising data, it’s approved all the way down to infancy. We’re going to have some great options there. So it’s not just me talking, Lisa can chime in, how has biologic therapy changed your practice, particularly in the case of young patients with bad atopic dermatitis?

: It has entirely changed it for the positive. I will think of my career in treating people with atopic dermatitis as BD, before dupilumab, and AD, after dupilumab, because it has revolutionized the treatment paradigm and what we can achieve for our patients in a safe way. For the first biologic, first systemic agent approved in the pediatric population for the treatment of atopic dermatitis, dupilumab hits a home run right out of the gate. I feel so lucky to have it and to be able to treat patients with it. It has been a life changer for patients, their families, and their doctor. It brings me so much joy to improve people’s lives in this way. In my patient population, I’ll take before pictures, before they go on dupilumab, and I’ll take after pictures, it can help with insurance and stuff like that. But more recently, I thought to myself, I should be taking a picture of the patients every time I see them, of their face, of what they come in wearing, because the metamorphosis, the transformation that occurs in these children and teenagers going on this medicine is profound and amazing, and brings me so much joy.

The first few visits, they don’t talk to me much, they have a hoodie on and sweatpants, and it’s 100 degrees outside. Then, they get on this medicine, and visit after visit, they’re shedding layers, they’re coming in in dresses and tank tops. They’re playing sports that their parents didn’t even know they had an interest in, but they were being held captive by their atopic dermatitis. I can’t express the gratitude I have for practicing dermatology at a time where I can witness this and be a part of it. It’s been profound.

: Have there been difficulties that you’ve found in terms of getting access, particularly for children, when it comes to biologic therapy with something like dupilumab? Any tips or tricks that you have in that regard?

: It’s all about persistence and perseverance, and fighting for your patient. I practiced for the first 10 years of my career in Colorado, where access to dupilumab was quite good. Then I moved to Idaho a year and a half ago. When I moved there, there were a couple of insurance companies that were requiring children to fail systemic immunosuppressants, methotrexate and cyclosporine, before they would cover it. My head just about exploded when I was exposed to that. And so, I fought against it. I wrote letters to the medical directors, and eventually, they changed their policies, thankfully. Because dupilumab is a wonderful medicine…I was never excited to put a patient on methotrexate or cyclosporine, I did it out of desperation. I wanted to try to help them. And now, it’s great to not have to pick among those anymore.

: I can bounce over to you, Taylor…. What was your experience in terms of starting dupilumab? Was it something that required a lot of waiting; did it happen quickly? What was it like getting on it from the patient perspective?

: It was game changing to my life getting on the medication. I was desperate to try to find anything that worked. I was at a point where the topical steroid creams were no longer having much reaction. As you spoke about earlier, the light therapy was something that definitely worked, but it didn’t sustain my lifestyle. I was in a professional career that required me traveling almost every week. And it wasn’t something that was going to work for my life. It worked for the atopic dermatitis, but it certainly wasn’t the solution that was going to fix it for me. With dupilumab, I would say, it was effective from the first injectable. I haven’t had any reactions since.

As far as getting on to the medication, it was quite a process, because my insurance denied the initial claims several times. I remember when I finally got approved, it was like the entire dermatology office had reactions you’ve never seen, because so many people had put so much time and effort into getting me approved for the Dupixent [dupilumab]. With the MyWay patient support program, it’s free for me, even though my insurance had denied the initial claims. I would say that that was something that I’d also never experienced, having medical professionals who were willing to stand up for me and fight my insurance to get me access to a program even though they wanted me to go through these leaps and hurdles.

I remember Dr Chovatiya told me that if I wasn’t someone who could get approved for dupilumab, then there was no reason the medication should even exist because I was the perfect candidate for it. There was a struggle getting through that, but once I was able to get on the medication, it has been completely life changing. And for me, I’ve changed jobs since then. I have had to go back through the preapproval process and all of that. But I specifically call the insurance company to ask them about this medication to ensure that I’m going to get coverage and figure out which insurance policy I should pick every year, because it’s something that I don’t want to live without.

: You highlight some powerful points about the fact that it seems complicated from both ends, right? From the medical side, you’re jumping through these hoops, fighting, writing letters like Lisa Elizabeth is to be like, “We need somebody to get this medication.” From your standpoint, you’re like, “When am I going to get this? I’m getting a denial, I’m getting a denial.” It’s hard to stay positive and motivated from both ends. If there are any payers and larger folks out there listening, this is an area where we need a lot of work to be able to help access it for our patients.

: I was going to say, I remember that I got the call from Dupixent on my birthday. And I was like, this is the greatest birthday gift anyone could give me, that I had been approved for the MyWay program. Ever since then, it’s been such a joy to be on it.

: From a patient perspective, you also highlight the fact that with many of these newer medications, there are mechanisms, even if there are issues with insurance, to try to help get our patients medications that they need. I applaud that effort to figure out ways that you can. Because many times, even if something is rejected, it’s a matter of being persistent as Lisa put it, in terms of fighting the battle to help get somebody the therapy they need. As we’re getting more new treatments, I hope this will be less of an issue. It’s going to be a matter of choosing between a lot of great therapies, and it remains to be seen if we’re going to have to jump through fewer hoops or not.

There have been a couple of exciting leaps in the therapeutic landscape of atopic dermatitis. We talked about biologic therapies in the last few years, but recently, there were a number of new oral therapies approved as well. I highlighted that JAK [Janus kinase] inhibitor class in the case of a topical medication, but there have been a few oral inhibitors of the JAK proteins that have come out. The data seem to suggest that these oral medications work fast, they seem to be good for people with moderate to severe disease who may have a lot of itch and a lot of lesions. The big difference perhaps between them and the injectable therapies is they do have some lab monitoring. I talked a bit about there being a boxed warning based on longer term studies in different patients with different diseases and different drugs in the same family that have to come into play when you’re having that discussion.

But I can say that for my patients at least 12 years old and up, it’s amazing to have another option in the armamentarium for control of their disease. As a class, JAK inhibitors have started to change how we think about different kinds of inflammatory disease, in addition to atopic dermatitis. And when you’re going to look toward the future, there are hundreds of trials going on in the preclinical phase 1, 2, and 3 programs for atopic dermatitis. What was once an empty tool box is going to get crowded very soon.

Elizabeth A. Swanson, MD, discusses the safety and efficacy of dupilumab in treating moderate to severe atopic dermatitis, and Taylor Capps shares her journey with dupilumab from insurance approvals through receiving treatment.

Role of Disease-Modifying Therapies for Atopic Dermatitis Treatment

: That brings me to talking about what are some of those goals for therapy that we think about when it comes to atopic dermatitis? As Lisa so beautifully highlighted with shared decision-making, there are different goals and values that every patient and family is going to have. Generally speaking, there are some universal things that people are looking for. When it comes to treatment, individuals want something that’s going to work, both in the short term and the long term. Not something that’s going to be a temporary fix. Something that’s going to keep working, not that one day suddenly, oops, it stops, and the atopic dermatitis comes back. Something that makes them feel safe, that they can keep using it. A bigger one that we don’t talk about is something they can access and get their hands on. So if there is a great therapy, they can use it, and it’s not some theoretical thing that they can use. 

When I’m thinking about patient factors when it comes to treatment options, very much as Lisa said, I love to lay it all out for my patients. Perhaps some might view it as over-information. I view it as empowerment. Because you’re never really going to know what is the best treatment for someone unless you talk to them about the options that are out there. You may have an idea in your mind of what you think you want to do, but at the end of the day, the best plans are not always the most feasible for patients. I would much rather have something in place that I know somebody’s going to be able to follow and a family’s going to follow through, than something that is either too complicated, too hard to get, is too expensive, and there are a lot of other patient day-to-day factors you want to think about when it comes to that therapy.

In terms of the state of the art as far as treatment goes, we alluded a bit to what that stepwise therapy, that diagram, looks like. The one extra element I might add is we always think about stepping up therapy. There's important power in stepping up and stepping down. Basically, not complicating the life of our patients too much. We’re all guilty of it, saying, “Here’s another cream. Here’s another ointment. Here’s another cream.” Pretty soon you come in with an entire bag of stuff being like, “I’m not exactly sure what I’m supposed to use.” On a day-to-day basis, I can barely remember to moisturize myself, and that’s just one thing. I could only imagine how difficult is if you have something for the face, something for your hands, something for the body, something for Tuesdays, something for Saturdays. A lot of our power is trying to figure out how we can make plans that almost remove an iatrogenic burden is the word I would use, where I’m not making your life too complicated, but something that’s going to work. We highlighted topical therapy as an important step for people with mild to moderate disease. Topicals typically work by reducing inflammation. In the case of emollients, they help with barrier repair on the skin.

Topical corticosteroids are the most commonly used. They range from low potency all the way to high potency. They come in a variety of forms, there are creams, ointments, lotions, oils, solutions, foams, for different parts of the body. This is usually the first place that most patients with atopic dermatitis start. Now, for a lot of folks, topical corticosteroids are a great choice. They’re pretty cheap, easy to access, and they can work really well. But you can run into issues with topical corticosteroids. Sometimes, they stop working for patients. Sometimes you need to use a more potent agent, but you’re limited based on a couple of factors. Usually in areas of thin and sensitive skin, you can’t use some of the strongest therapies we have. We run into problems of skin thinning, loss of fat under the skin, even pigmentary problems on the skin. When it comes to the face, and body folds, and genitals, these kinds of areas, there are huge limitations on what therapy we have. Additionally, with chronic use of topical corticosteroids or any topical, there are some small levels of absorption of anything that you’re using. You could imagine that years of use of topical corticosteroids could also lead to other issues down the road as it relates to just chronic use of steroid-based therapies.

There are other topical therapies that Lisa touched on. We have calcineurin inhibitors, phosphodiesterase-4 inhibitors, and then a newer JAK inhibitor as well. These all work by specifically targeting different molecules. So where topical corticosteroids are a little more broadly acting, they generally reduce inflammatory activity, topical calcineurin inhibitors are a little more specific. Still very broadly acting, but they’re nonsteroidal. They do eliminate some of the issues that I mentioned with topical corticosteroids. The downside there is that they can commonly be associated with stinging and burning, particularly in areas of sensitive skin, and there are only a couple of options, tacrolimus and pimecrolimus, both of which have limited efficacy. Sometimes you’re not going to get the boost that you need from these medications.

There’s one phosphodiesterase-4 inhibitor on the market, this is a specific molecule that inhibits one overactive enzyme in the skin in atopic dermatitis. Crisaborole is what that one’s called. Again, this one is probably overall limited by potency, and this one probably has the highest rates of cutaneous symptoms in terms of stinging and burning and itching. It’s not exactly the easiest therapy to use for patients. A newer one, approved for ages 12 and up, is topical ruxolitinib. This is what’s called a JAK inhibitor. In broad terms, this is a specific targeted therapy that works on a class of proteins that are overactive in the case of atopic dermatitis and involved in a lot of different signaling pathways that are related both to what’s going on to the skin and symptoms like itch. This one does have good potency. It isn’t a steroid, so you don't worry about some of the steroidal adverse effects. There are other issues to contend with. This entire family of medications, JAK inhibitors, do contain a boxed warning, which is another important part of that shared decision-making discussion, based on some long-term studies with older oral medications in that same class as well. There’s a little more discussion that goes into using this one to think about if it’s the right medication.

At that point, if topicals aren’t doing it for you, this is where you start stepping up to more advanced therapies in the moderate to severe range. Phototherapy is a classic one, narrowband UV-B [ultraviolet B]-based therapy. It works well. It is a bit cumbersome for patients to use, it’s a little more historical in that sense. Typically, patients have to go to the office at least 3 times a week, stand under a light box, and get a specific wavelength of light that can help reduce inflammation on the skin. The downsides are it’s slow acting, and again, patients often physically have to go somewhere. Classically, we’ve used oral immunosuppressive therapy, so methotrexate is a classic one for atopic dermatitis. Cyclosporine is another one, azathioprine is another. These are all medications that have been the standard, and still are in many other countries around the world. They work, not great, but they work, but there are some downsides. You have to monitor laboratory test results. There’s a whole host of potential issues related to blood, liver, kidneys, that you have to monitor. For people who have bad disease, these were what we had to contend with for years.

Raj J. Chovatiya, MD, PhD, reviews goals of therapy for patients with atopic dermatitis and comments on the use of various topical therapies and systemic agents for disease management.