Three dermatologists discuss the case of an 18-year-old patient with AD who is exploring nonsteroidal options to manage his disease.
Neal Bhatia, MD: I’m going to bridge into this last case, and then we’ll talk about some other things in the pipeline. Here’s an 18-year-old; obviously, we’re going into a 4-year-old, 12-year-old, 18-year-old, the magic numbers. The 18-year-old is an adult now, but he’s Fitzpatrick skin type 3 with chronic atopic dermatitis. He came to the dermatologist with worsening of flares around the popliteal and antecubital fossa, all over the arms and the abdomen. So there is a lot of surface area involved. He was first diagnosed at age 5. This patient’s had a lot of dusky colored plaques and a lot of low-level flares that were darker, but yet not as much texture if you will.
The treatment here was, again, moisturizers and steroids. The steroids started to wear off their efficacy, and there were more side effects. A lot of steroid atrophy consequence with bruising, a lot of nonhealing wounds from the steroid. Long-term steroid use is an issue here, and the patient obviously said, “No mas, I don’t want any more steroids.” Angela, I’ll ask you, now we have an adult, we have different locations, they’re obviously prone to steroid atrophy. What can we use in the history here to have some strength in getting some other drugs covered? We have 4 or 5 big topics here to use to our advantage.
Angela Lamb, MD: Absolutely, that’s often what they want to see. This would be a person who would be perfect for tralokinumab or dupilumab, they would be perfect for these or one of the oral JAK [Janus kinase] inhibitors. When you have people who have failed, that’s what the companies want to see. The insurance companies are the big holders, unfortunately, to your point Neal, of our patients’ fate sometimes. They want to see that they’ve tried and failed all these things before they’ll cover something else. This would be a patient who I’d be much faster to give 1 of those medications, to talk them through pros, cons, and side effects. Again, this is an adult, and often I find it’s easier to have conversations with adults than with pediatric populations, because I feel like people get more concerned about their children or what may happen to their children’s developing organs than they are about what might happen to themselves. But I think those would be appropriate, and again, just documenting what has been tried and failed. That’s where we would need to go, and it should be approved with no problem, ideally.
Neal Bhatia, MD: Exactly, that’s important. Omar, take the spin of maybe this patient doesn’t want to be on shots. We have topical ruxolitinib, oral upadacitinib, and oral abrocitinib as options. What would you talk to the patient about with those ideas?
Omar Noor, MD, FAAD: I think you bring up a good discussion point regarding the topical steroids. I love to stress this point, we have to be careful with anything we prescribe, prescription wise. We want to be careful about the side effect profile. A cream like a steroid cream does not come without its own concerns. This patient has atrophy leading to potential tearing and bruising, and these are topical steroids that when used inappropriately can cause disfiguring results. It’s a great opportunity to take a step back, discuss with the patient appropriately, and talk about different options where we don’t have to worry about atrophy, and we don’t have to worry about the steroid side effects. This patient doesn’t want shots, but with dupilumab, we don’t have to worry about those things.
You mentioned topical ruxolitinib; this has been a very nice addition to my practice because it is a steroid-sparing topical Janus kinase inhibitor, and it is approved for patients 12 years of age and older. Yes, it does come with a boxed warning that is associated with oral medications that have been approved in this class of medications, but we see in the actual clinical trial for topical ruxolitinib that we don’t see a lot of those issues that they see in the boxed warnings. In my practice thus far, I have not seen any of those boxed issues. However, I talk to patients about it, I say listen, “This is where this information comes from. It’s from previously approved medications that are oral, not topical, and I feel very comfortable utilizing this medication, because we don’t have to worry about atrophy for you.” That’s a good place to start.
Now we know that atopic dermatitis is very complicated. There are a lot of different factors that could influence it, it waxes and wanes, and it can have moments where it gets really bad, and then it can have moments where it’s a little more quiescent. But we want to make sure that we’re treating this patient longitudinally. In this patient who sounds more moderate to severe, yes, a topical ruxolitinib can be effective to minimize the steroid atrophy, and if the patient doesn’t want to go on shots, a topical Janus kinase inhibitor would be the next step for them. Going through those boxed label warnings, going through what I have seen in my clinical practice, and going through what has been seen in the clinical trial helps us create a framework of what to discuss with the patient. Treating the patient from there would be my next step.
Neal Bhatia, MD: Those are good, and it kind of bridges the differences between the therapies, especially when it comes to speed, because we know the JAK inhibitors are making a big impact, even as early as day 3 in a lot of these patients, from what we saw in the trials. Given this patient’s frustration, fortunately, we’re not dealing with asthma and the other consequence of atrophy like with the 12-year-old, but in this patient we can say, “OK, let’s try to put out the fire and get it out as fast as we can to break your itch/scratch cycle.” This is where some of the topical agents, as well as the 2 others, might have a big advantage in at least getting the patient out of his own jail. Just saying all right, “let’s get you back to a steady state,” and then 3 months later switching gears from pills to shots could be an easy option when you take away the safety signals as well as some of the other issues that might be concerning to them.
You brought up all the big points about the black box issues as well as the talking points, but the other nice thing about it is we can take steroids out of the equation to some degree, because that’s what this patient’s issue is really about. And the same with tralokinumab here, now it’s indicated at age 18 and has an option for once-a-month dosing. If we got that patient at a steady state and put them on once a month, that could be something of value also. So there are a lot of different ways to approach it, but again, just being cognizant of the risk of steroids, especially in a darker-skinned patient who’s Fitzpatrick 3 and 4. In that group, I think that it is really something to take into account.
Transcript Edited for Clarity
Case 3:Patient With Medium Brown Skin
An 18-year-old FST III [Fitzpatrick skin type 3] with chronic AD [atopic dermatitis] presented to his dermatologist with a worsening of rashes that are raised and itchy, and include popliteal and antecubital fossae, arms and abdomen.
The patient was first diagnosed with AD at the age of 5 years. His rashes initially appeared in areas of low visibility and were darker in color. Treatment included moisturizing therapy and topical corticosteroids. Treatment with topical corticosteroids became less effective over the years, and the patient also started experiencing side effects including easy bruising and tearing of the skin. He is worried about long-term steroid use and does not want to use topical corticosteroids going forward.