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Approaching Treatment Selection in AD


Drs Lamb, Noor, and Bhatia discuss their approach to selecting treatment in light of recent AD approvals.

Neal Bhatia, MD: Angela, I want to ask you about your approach with kids. How much different will it be compared with what we do with adults? Obviously, the 2 JAK [Janus kinase] inhibitors out are for 12- and 18-year-olds. Upadacitinib is 12, abrocitinib is 18, dupilumab is now 6 months, and tralokinumab is still 18. But then we go back to the basics, like crisaborole, tacrolimus, or even steroids. Is there going to be much of a difference in the way we approach kids compared with what we’ve had with adults until now?

Angela Lamb, MD: I’ll be honest, especially with this new armamentarium, I won’t change necessarily my approach, except for the parents. Parents are the biggest barrier. The only thing I might have to get around is, do I think this person has severe enough penetration of disease that I want to have that conversation with a parent of a 12-year-old or a 6-month-old to say, “Let’s maybe try an oral. Let’s try an injection.” That’s an easier conversation to have with an adult who’s treating themselves than it is to have with a parent if someone has a burden of disease where topical medications are appropriate. You mentioned several. I have almost no difference in how I manage those patients. But when we’re talking about severe disease—high EASI [Eczema Area and Severity Index] scores or IGA [Investigator Global Assessment]—those are the folks with a child about whom I have to think twice before having that conversation, or if I think I can get them where they need to be with the topicals.

Neal Bhatia, MD: It’s interesting because 1 thing we tend to forget is the moderate patient. The severe patient makes all the headlines, but it’s that moderate 10% to 20% that we would otherwise be giving prednisone to or throwing steroids at. We forget about that patient. I joke sometimes that it’s the patient who’s at the traffic stop and scratching, or the 1 sitting in their cubicle, who can’t think about anything but their itching. But the moderate patient is probably still walking and talking. Omar, this is not just with treating kids, but in getting over the hump, is anything a driving factor? Who’s a shot patient? Who’s a pill patient? Should we always be treating from the top down, is there anything that’s a driving force behind that?

Omar Noor, MD, FAAD: My No. 1 criterion is that I want to get you better. I tell every patient that my goal is to get you better, but I also want you to be on the least amount of medication to stay better. Because of that, we’re looking at efficacy, but we’re also looking at that safety profile. For that moderate patient sitting in the car, I like to give a scenario: it’s a beautiful summer day, you’re in the pool in the morning, you go for lunch, you’re eating a burger, you’re sitting there for 2 hours, maybe you have a beer. Suddenly, you just start shifting in your seat, your swimming trunks get a little itchy, and you’re shifting. For some of our patients, that’s the best that they feel in their entire life. Flip that around, we’re in New York City. Imagine shifting in your seat like that when you’re in a boardroom discussing a $44 billion sale of Twitter. If you’re shifting and uncomfortable, you can’t focus. In this world, in the United States, you have to be on your game 100% of the time. If you’re not, then we need to fix that. For a patient like that, even though they may not technically fall into the right bucket for body surface area, that’s a shot patient because I want to improve your itch. I want you to be on a medication that’s easy for you to use, where you’re injecting it twice a month, in an adult. I want to see the improvement. From a safety profile, I want to feel comfortable prescribing it to you.

Neal Bhatia, MD: Those are great examples. I have a lot of patients in the Navy and Marine Corps, and it’s exactly that. You’re in your uniform on duty, and the last thing you need is something else.

Transcript Edited for Clarity

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