He delves into one of his most challenging recent cases, the evolution of treatment options, and strategies to think outside of the box in diagnostic and therapeutic approaches.
Raj Chovatiya, MD, PhD, Dermatology Times® editorial advisory board member, board-certified dermatologist in Chicago, Illinois, will present in 4 different sessions at Maui Derm NP+PA Fall 2023 in Asheville, North Carolina from September 27-30, 2023. He shared a sneak peek of the real-world experiences he has had that conference attendees can learn a wealth of treatment pearls from.
Dermatology Times: What do you enjoy most about presenting at Maui Derm NP+PA meetings?
Chovatiya: It's a really great experience to go into the NP+PA meetings that Maui Derm sponsors because it's a high-yield hit list of all the things you really want to get across to somebody that is be very new to dermatology or someone who might be very, very experienced. Amazing faculty. And you know, honestly, the goal of this meeting is to step up education for everybody that seeing patients out there, and that includes our NPs and PAs. I think it's critical that at the end of the day, whoever is going to be that primary person seeing patients for their cutaneous concern, has the highest level of knowledge just for that reason alone. It's really my pleasure to participate in education.
Dermatology Times: Red, itchy rashes are common and can be a mystery. What inspired the session "Contact Dermatitis Versus Something Else?"
Chovatiya: One of the big challenges we face in dermatology is trying to figure out: When is it eczema? What isn't? And then within eczema, are we looking at atopic dermatitis, contact dermatitis, [or] something else altogether? So in this session, it's really 2 great minds coming together to kind of talk about the way we approach all those red itchy rashes out there. And I think the biggest takeaway is understanding that, number 1, nomenclature matters. Atopic dermatitis and eczema are not exactly the same thing. Eczema kind of a group blanket term for a lot of different conditions that can show similar findings of which atopic dermatitis is one of the most common, but contact dermatitis also falls in a bucket as well. I think really understanding the diagnostic criteria for clinically diagnosed diseases like atopic dermatitis, it's really important to define what that is. And then understanding when are the times we should be thinking about something else in terms of clinical clues where you may suspect a contact dermatitis, for instance, and whether there are certain geographic involvement on the body or things are flaring at a time where they shouldn't be.
Really, I think, at the end of the day, dermatology is very much like a mystery game. And I think that in the area of inflammatory diseases, particularly your red itchy rashes, it's a little more fun that we get to have in terms of figuring out what's going on using everything that we hear everything we see and sometimes even additional tests.
Dermatology Times: In the session "Hot Topics in Inflammatory Disease," which conditions will you spotlight and why?
Chovatiya: This is a bit of a newer session in the way that we tried to combine diseases that oftentimes don't get the spotlight because you hear a lot about atopic dermatitis. You hear a lot about psoriasis. But we really wanted to highlight some of the areas where there's a lot of therapeutic innovation happening, and so we're going to be covering updates and highlights and even basic background information in hidradenitis suppurativa, chronic spontaneous urticaria, and vitiligo. And in the case of HS, I think it's 1 of the areas that we all struggle for treatment, just because we don't have that many options and it's a very hard-to-treat disease. In my quick overview, I really delve into why the immunopathogenesis is so complicated and some of the exciting treatment coming our way. IL-17 blockade appears to be a real legitimate place to start when it comes to treatment. And we're hopefully going to be having a couple treatment approved in this regard, hopefully within the next year and almost imminently. And then also JAK inhibition is another mechanism to that's proven to potentially be really important for HS treatment.
In the case of chronic spontaneous urticaria, we oftentimes think about this as an allergy disease and not a derm disease. But really, it's a common condition that our patients come to see us for. And so I really just tried to do an overview of what CSU is, how we can diagnosis how we should feel comfortable with it in dermatology, and what are our treatment options currently today. And it looks like we're beginning to understand that perhaps type 2 inflammation may be 1 of the mechanisms in this disease. And we may have some new biologic therapies that we will feel very comfortable treating our patients with. Finally, in the case of vitiligo, we've seen sort of things change from a pre-JAK inhibition to post-JAK inhibition era. And so really, what we're going to try to do is get a good update of what's going on with topical JAK inhibition at this state and take a peek at some of the oral JAK inhibitors that are currently under investigation for large scale expanded vitiligo.
Dermatology Times: The session "Challenging Cases" will draw upon your skills in difficult diagnostics and therapy. What are you presenting?
Chovatiya: Anything could theoretically be a challenging case, when the first thing that you did, or first thing that you tried, doesn't work. In my section of this talk, I'm talking about a particularly memorable and challenging case of hidradenitis suppurativa or HS that I had. And in this particular instance, the patient actually came to me not necessarily with HS as their primary complaint, but due to some other medical factors and features, it led us to understand that HS was perhaps at the root of things. And then it became a bit of a treatment challenge given how refractory this disease was potentially to treatment, and then some of the really interesting comorbidities that came along the way and how we chose to handle that. So in this circumstance, maybe the challenge wasn't necessarily getting at the diagnosis, but it was really trying to, you know, move with the twists and turns that happened along the way as far as the actual clinical horoscope. And that's kind of a good lesson for all of us because a challenge you face doesn't necessarily have to be something that you can't diagnose or something that doesn't necessarily respond to the first line treatment. That oftentimes happens all the time, really the totality of what happens over the course of several years, in terms of associated things, comorbidities, or other challenges that you're faced.
Dermatology Times: You are presenting in "Atopic Dermatitis Update 2023." Tell us about the evolution of AD treatment you've experienced throughout your career.
Chovatiya: I think that we probably divide our eras to really a time when we didn't have any targeted systemic treatments to around 2017, where our first biologic came around for us, having targeted at the director of atopic dermatitis. Since then, it's really been a fascinating journey punctuated by a lot of activity recently, in the past couple years for different mechanisms that have been targeted in terms of disease. And I remember when I first started treating atopic dermatitis: topical corticosteroid, photo therapy, and oral immunosuppressive. There really wasn't much in the way of treatments that were highly efficacious, rationally developed, targeted, and ones that were really designed to treat the disease of interest. And then following the advent of dupilumab, it's really changed the way that we think about treatment for this disease, and understood really the true burden our patients with moderate to severe forms of atopic dermatitis face. Following that point, and upon building what we understood about IL-4 and IL-13, we saw the approval of tralokinumab, an IL-13 specific biologic therapy. We saw the approval of 2 JAK inhibitors, a different mechanism that targets cytokine signaling in a different way, perhaps one that is even a little bit more broader than a biologic therapy. And so abrocitinib and upadacitinib were approved in our landscape. It looks like we may potentially be having another biologic therapy any day now, lebrikizumab, another IL-13 targeted biologic being approved as well. And it hasn't just been magic happening in the systemic space. But topical space is in a flurry of development as well. And so crisaborole, a handful of years ago, was sort of our first new mechanism and along with time as a PDE4 inhibitor, which you know, has its pluses and minuses and patients who it might be a good choice, but really topical ruxolitinib was kind of the first flag in the sand of a highly efficacious targeted therapy that really worked with an MOA that could cause itch resolution very quickly, help patients with their lesions very well, and now we're seeing for some of the other emerging therapies including...roflumilast. We might be actually be seeing a mini renaissance in topical therapy, which we desperately needed.
Transcript edited for clarity