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AD Patient Case: FST I


Experts discuss the case of a 4-year-old girl with lighter skin and treatment options for a young child.

Neal Bhatia, MD: With that, I want to give us some cases to review. Maybe we can break down some of the nuts and bolts with that. I’ll give you 3 different cases. I’ll read them to you, and we can review how we would take care of them and what our impression is.

The first case is a patient who’s Fitzpatrick skin type 1 to 2. She is 4 years old was previously diagnosed with moderate atopic dermatitis. She was and referred to the dermatologist with red, dry, itchy patches on the arms, which is what we’d see with a first-time patient, especially from a nondermatologist referral. She’s been treated with nonpharmacological agents, such as emollients and moisturizers, given multiple topical steroids, probably in generic vehicles. Since 6 months old, she has been on steroids cyclically. Her parents have noted that the rashes and itching keep progressively getting worse each year. After 6 months of being diagnosed and now being 4 years old, things are starting to roll downhill.

When talking with dermatologists, parents keep mentioning disturbed sleep, missing preschool because of poor sleep, and having to take time off work for all that. The parents don’t sleep either. They dress her in long-sleeve clothes even on hot days, doing more to avoid peers and the other little kids from seeing what’s going on. The family is trying to hide the scratch marks on her arms. You can get the essence that the disease is progressing. There are definitely a lot of psychosocial issues involved with both the child and the family. Trying to manage things from behind has been the approach. Omar, I’ll start with you, what’s your initial thought? Obviously this patient has a lighter skin type, itching is either in proportion or even out of proportion of the rash, and then everything else that goes with the nonpharmacological management aside from steroids. What’s your impression of what’s going on so far?

Omar Noor, MD, FAAD: It sounds like this young child has a more moderate atopic dermatitis, with the itch obviously playing a large role in that. Her body surface area is not dramatic because she’s so small. But we know that the symptoms also can contribute to what we classify as a more moderate patient. It sounds as if they’re doing a good job with their emollients and skin care. We don’t have to have a crazy discussion around washcloths, loofahs, things like that, and using Irish Spring for instance. Talking about our gentle cleansers and things like that—an overall barrier discussion.

Beyond that, we see how much this is affecting her life. We have a very suitable option in dupilumab that has now been approved for 6 months of age. We know that these psychosocial issues that you discussed will affect her growth, her ability to learn, and everything else—her ability to sleep, her family’s ability to cohesively live together. If we can improve her itching, her scratching, and her eczema with something like a once-a-month injection with dupilumab, that can positively influence the entire family dynamic.

Neal Bhatia, MD: Yes, but it’s also important to get at the cycle early—the amount of surface area but also the amount of itch, as you just described. Those are significant drivers to that. Angela, we talked about age with the new indication of dupilumab, the location, the amount of surface area. What other adjuncts besidesdupilumab would go along with it. How would you incorporate dupilumab in that discussion? They probably have been used to treating from the top down, and now we’re adding something a little more systemic.

Angela Lamb, MD: I don’t know what your clinical practice has been. I love dupilumab, but I often find that everybody has 1 or 2 little resistant patches, particularly patients who are so severe. You always want to have something topical for people to use, so definitely in these circumstances. I love crisaborole. It’s a great nonsteroidal option. Also, we need to continue the religious barrier protection and emollients. Even for my patients on dupilumab, I always tell them you should treat your skin the way you were treating it before. Let’s be compulsive about the reapplication of the emollient and using the gentle cleansers. As Omar said, don’t use the Irish Spring. Don’t think you can all of a sudden start using all this fancy fragrant stuff. Let’s keep it simple. Apply emollients religiously 2 to 3 times a day, and then you always could use a medium-potency steroid for those breakthrough areas. As much as I love the medication, I find that almost everybody has that little breakthrough. Sometimes it’s hard to know if they’re not moisturizing as religiously now that their skin is so much better and maybe they just need to put on more emollients, but I like to give people options that they can use in those cases.

Neal Bhatia, MD: Yes, breakthrough is my favorite term. You hit it right on the head. There are going to be stubborn areas, there’s going to be as such. Even days where the kid goes swimming or something else, that’s the time to add another layer of moisturizer, for example. I try to make sure too to put steroids back into context because. If they’ve been dependent on steroids, and now we’re switching gears and go into biologics, we can still use steroids effectively and not be reliant on them. It puts everything back into getting rid of some of the phobias and misconceptions.

As we talked about clinical research, in 18-year-olds, every 1 of those drugs—crisaborole, ruxolitinib, upadacitinib, dupilumab, tralokinumab—have had contingencies for rescue therapy and for adding on. Then the KRONOS trial for dupilumab and a couple of others were done with topical steroids. The Measure Up trial with upadacitinib and a couple of others also did that. Putting it into context where we can use steroids effectively but not be dependent on them will get more of the parents onboard.

The other part of the equation is proving that the safety has been approved by the FDA for 6 months. That gives us a lot of leverage in getting these drugs covered. You guys hit on some good points.

Transcript Edited for Clarity

Case 1: Patient with Pale/Fair Skin

A 4-year-old girl previously diagnosed with moderate AD was referred to a dermatologist with red, dry, itchy patches on her arms. She has been treated with non-pharmacological products (emollients and moisturizers) and multiple topical corticosteroids since her diagnosis at 6 months of age. Her parents noted that the rashes and itching have been getting worse for past one year.

When talking with dermatologists, her parents mentioned disturbed sleep causing her to routinely miss preschool. Parent admitted to sometimes dressing her in long sleeve clothes even on hot days to avoid her peers and family from seeing scratches on her arms.

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