Best Practices in Managing Atopic Dermatitis in Skin of Color - Episode 2
Dermatology experts discuss strategies to increase awareness of advances in AD in patients with SOC.
Neal Bhatia, MD: Omar, take that a step further, focusing on darker skin types, Fitzpatrick scale 4 to 6 for example. In skin of color populations, the different endotypes, different immune mechanisms, barrier features, all of those different things come into play. What do you talk about with your patients, and what can we learn from what we’ve seen so far?
Omar Noor, MD, FAAD: Dr Lamb, you brought up a very good point about darker skin types and their overall different nuances on a cytologic level, they are having different cytokines that are being expressed. Hopefully the more information that we learn, starting here, will give us more information down the line to help better treat them. In clinical practice, when having the opportunity to talk to patients, we know that a lot of cultural practices can come into play. It’s about making sure those patients are aware of different bathing practices, like you mentioned. We know that if we’re scrubbing the skin too much, if we’re exfoliating, sometimes if we’re just simply using a washcloth or a loofah, that might contribute to exacerbating someone’s atopic dermatitis or someone’s skin condition. Whereas normally patients grow up treating their skin a certain way, there may be nuances to the way that they treat their skin that may be making it more difficult for us to help them get better. Having good communication with patients, especially in dermatology but in all of medicine, is critical to providing the best care possible.
Neal Bhatia, MD: Those are good points. Even more so, it’s directing patients to the resources we want them to follow so they don’t get the wrong information, whether it be from social media, Dr Google, or the neighbor next door who knows more than we do. We always say, “Your Google search is not as good as my medical degree.” So it’s probably worth having that same conversation. With that, how do we bridge some gaps? Obviously, you both are well versed in both the therapeutic options as well as some of the basic science. How do we get some of the average Joe dermatology to get in line with the way things are moving ahead. That it’s not just about triamcinolone, ointments, and antihistamines, and there’s more to what’s under the hood. Angela, I’ll ask you, from what you see in your relationships with some of the colleagues in both academics and private practice, what resources should we be directing patients and colleagues to? What other talking points should we be focusing on?
Angela Lamb, MD: The main talking points are the exciting things that are coming down the pike with all these new medications that we have available. Like you said, it’s beyond triamcinolone and antihistamines. Then also, some of the biologics; I know, I used to give methotrexate and all of that type of stuff for severe atopic dermatitis. I’m incredibly excited about what’s been going in the last several years. We have, again, some oral JAKs [Janus kinase inhibitors], we have dupilumab, it’s exciting. Then we have some new medications that just came out in the last couple of months. I think that really tears the lid off and gives people options, because what I see so often with darker skin tones is that it’s not just the atopic dermatitis, it’s also the hyperpigmentation.
People are really concerned about being scarred, and so my threshold is a little lower. I want to talk to them about these new treatment options a little sooner sometimes, because they can have that lasting post-inflammatory hyperpigmentation that can be so disfiguring. Ideally, if we can stop the cycle of the damage to the skin, the skin will repair itself. But I’m sure you can all attest, sometimes I see people who have had such long chronic atopic dermatitis that some of that hyperpigmentation is stuck. I want to get them past that level sooner rather than later.
Neal Bhatia, MD: Omar, I’ve heard you lead the charge in training on topicals and on systemic medications. What kind of talking points about what is FDA approved and what is standard of care now would you give in terms of teaching everybody else?
Omar Noor, MD, FAAD: With these newer medications and the way that we talk about education and discussion I think falls into 2 different buckets. We have educating our colleagues or physicians, and then we have educating patients. I think the educating of physicians, when it comes to skin of color, starts with clinical trials. Our current mechanisms or tools for evaluating erythema in clinical trials are flawed. And because of those flaws in evaluating patients at baseline, the clinical trial percentages and results that we have grown accustomed to for our systemic and topical medications don’t fully encompass what type of benefit our darker skin-type patients are getting. Sometimes it doesn’t fully capture the severity of some of our darker skin-type patients, especially in atopic dermatitis.
My education starts with, this is what an IGA score, or an investigator global assessment, is. This is what an EASI [Eczema Area and Severity Index] score is. Then we look at photos of darker skin types to appreciate that the erythema that is a major component for evaluating these patients for clinical trials is more difficult to assess in a darker skin type. Then unfortunately, on top of that, the way that these clinical trials are run and recruited, it’s difficult to get a large percentage of patients for these clinical trials in these darker skin types, whether they’re brown patients or Black patients. We start with, this is what we have to work with, and these are the results for our options that we have for these patients. But then we take a step back and try to appreciate the entire picture on how can we use these options for our darker skin types in our practice. That’s where I’ll start.
Neal Bhatia, MD: That’s an excellent summary, and you hit on a couple of big points too. I think all the dermatologists out there should think about incorporating EASI scores, BSA [body surface area], IGA, and all of these other big talking points in their clinical assessments. What we do in research can easily translate to clinical practice. It’ll help bring objective measures to how things are going, but it also help get some of these systemic drugs covered. A lot of dermatologists unfortunately I think have given up the fight on trying to get the FDA-approved drugs covered, whether it’s biologics, the JAK inhibitors, and others. We all go to these conferences, and everyone complains about cost of care and cost of drugs. I can’t emphasize enough the cost of not treating these patients. The costs of patients staying up at night scratching, not going to school or work, parents who have to lose sleep, and even more.
So all of these indices, and even a little harder to get surveys like POEMs [Patient-Oriented Eczema Measures] and DLQI [Dermatology Life Quality Index], these are big tools that we can all be using to integrate what we’ve learned in clinical research into our clinic notes. It just takes a bit of work. Even an NRS [numerical rating scale] score, the 0 to 10 scale, can be done in minutes. It would significantly add to our understanding of progress. But again, you guys both bring up excellent points on how to translate what we’re doing in trials as well as more advanced stages of learning. Getting everybody else on board would be great.
Transcript Edited for Clarity