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Approaches to Managing Atopic Dermatitis


Diego Ruiz Dasilva, MD, FAAD, shares treatment approaches to atopic dermatitis, focusing on medications such as dupilumab and upadacitinib.

Diego Ruiz Dasilva, MD, FAAD: I want to discuss a bit about my approach to treating atopic dermatitis with you. I have a fairly standardized but customizable approach. My primary goal is to focus on symptom relief and to improve quality of life. There’s always a lot of talk about the root cause, but it’s often out of our control in the sense that practicing gentle skincare can optimize the skin barriers. You were mentioning moisturization, but it’s unlikely to cure it because it’s a complex, inflammatory pathophysiology, it’s not as simple as just gentle skincare. But to that end, I normally recommend thick plain emollients, elimination of skin scrubbing, switching of all personal care and laundry products to unscented low-irritancy alternatives.

In addition to this, at the first visit, I’ll typically recommend a topical steroid and a nonsteroid flare and maintenance plan. Sometimes I’ll incorporate a short systemic steroid burst to help with severe itching and then see patients back in the next 1 to 3 months to see if this has provided positive quality of life and adequate resolution. If not, I quickly move forward to the FDA-approved systemic options. And I want to talk about those options.

Dupilumab absolutely changed the game and revolutionized the treatment of atopic dermatitis. Prior to its arrival, we were forced to use numerous systemic steroid courses and then traditional steroid-sparing immune-suppressing medications that were the lesser of 2 evils, but still risky. Dupilumab arrived with remarkable efficacy, and more importantly safety that boasts immunomodulation and not suppression. Thereafter, topical and oral JAK inhibitors have again disrupted the landscape, providing highly effective nonsteroid alternatives that are FDA approved and well tolerated. While topical JAKs can minimize our use of topical steroids in the mild to moderate group and prevent long-term skin atrophy, it’s oral JAKs that truly excite me. Their efficacy surpasses dupilumab and provides an oral option for those who are not comfortable with needles. They do have more potential risk, however, that risk is overblown by many, and a lot of recent studies have shown them to be very safe. That’s the main reason I put you on upadacitinib, which is one of the most effective atopic dermatitis therapies.

You were in a unique scenario, but unfortunately a common scenario among many patients with atopic dermatitis, showing up with a really severe case, with it being all over the place, and you being ridiculously itchy, with none of the topicals covering it. It left me as the clinician feeling like if I give you any oral steroid medicine or immune suppressant, I’m either going to cause you more harm or provide this false hope of a bandage, where you’re going to feel OK for a couple of months and then be back at square one.

Trinity had somewhat of a unique first-time eczema visit because your eczema was very severe, to the point where I was surprised that you had not gone to an ED [emergency department] or something, I think because you’re tough. You were just living with it and being diligent with trying to put on your topical medicine. But you had tried, mid potency topical steroids, maximum potency topical steroids, even at twice daily usage for months at a time, which is more than we’d recommend. You had tried the nonsteroidal topicals too, and they were not cutting it. So, even from the very first visit I was contemplating putting you on oral steroids vs a systemic treatment. I basically, had talked to you about all the options, saying, “An oral steroid might make you feel better in the short term, but it’s simply a bandage, and certainly we can do that anyway, regardless of what treatment we choose. But with your degree of eczema and how long you’ve had it, it’s not a cure.”

Then we talked a bit about the injectables, dupilumab, and injecting yourself every 2 weeks or every month, depending on some of the other biologics. Then we talked about the oral JAK inhibitors, like upadacitinib, taken daily, which are very effective, requiring occasional blood work monitoring, but also providing this "cure-like” experience for many patients in their trials.

My personal approach is to let the patient make the decision. We make it together, but I really want to know what they think. To Trinity’s point, you were very vocal in telling me,” I want something very effective. I like a pill option because I already take something, and I can easily implement it in my daily routine.” So that’s how between 1 and 2 visits basically we made that decision and worked on insurance authorization and all that. Unfortunately, it’s not as quick as it could be. I’m curious if you have anything to add to that, Trinity.

Trinity Flint: The only thing that was an issue with the entire process of getting on my treatment was the insurance, and that wasn’t even that big of an issue for me, thankfully. I knew this was going to be a better experience when I came and saw you the first time because you were the only doctor who was willing to do a skin biopsy to medically prove that I have eczema. I’d never had that done before, and that was already a little light bulb in my brain.

Diego Ruiz Dasilva, MD, FAAD: I love to hear that because I get surprised sometimes when I see patients who have dealt with something as long as you had dealt with it and as severe as you had dealt with it, and no one had moved that needle. The same results from visit to visit, no skin biopsy to prove what you had, and no discussion of more advanced systemic treatments. It’s really surprising to me. I’m glad we were able to have that conversation and we had the back-and-forth to pick something that worked well.

Transcript edited for clarity

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