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Ongoing Challenges in the Management of Atopic Dermatitis


Experts share insight on the challenges inherent in treating patients with atopic dermatitis despite recent advances in therapy.


Christopher G. Bunick, MD, PhD: We’re going to move on to our final segment, discussing challenges that remain in atopic dermatitis and the future directions for our specialty in atopic dermatitis. Dr Lio, if you could, kick us off for this segment. What do you think might be the barriers to patients obtaining JAK inhibitors for the treatment of atopic dermatitis?

Peter A. Lio, MD: There are a couple. It begins with clinician comfort. There are going to be some clinicians who say, “I don’t want to get into this. I’m a little concerned by this.” We know that this is true of other systemic medicines within dermatology, and allergy as well, and even some of the biologic agents, which are fairly approachable. But there are many clinicians. I’ve learned this over the years: they say, “No, I don’t do it. I’d refer those out if they needed it.” So that comfort is important.

The second big barrier is going to be for patient comfort. They have to be willing to look at that fairly scary black-box warning and go through it with somebody and feel like the benefits outweigh the risks. I’ve already had some patients who say, “I don’t want to do this. It sounds too scary to me.”

Then we have the access. So far, we’ll say that both companies that have made the JAK inhibitors that are out are committed to getting them in patients’ hands. But we’re also a little older and jaded. We understand that sometimes the honeymoon phase means everybody gets it easily, and then a few months later, suddenly we’re pushing against the brick wall. Hopefully they’re going to be committed. We’ve seen with the biologics, which are also very expensive medicines, that most patients in need can get them, but there are certain insurance situations. The bane of my existence is Medicare patients, who have just as much need as anybody else, but the government program doesn’t allow them to take advantage of certain rebates and discounts, so they end up being very stuck. I have a big issue there. The Medicaid population has the same kind of limitations. These are issues we need to figure out how to surmount.

Finally, how do we get patients off it? I love what Dr Stein Gold was saying about putting a patient on a medicine that has a potential series of risks, especially ones that are probably going to increase over time. With anything immunosuppressive, it’s that volume under the curve, the depth of immunosuppression, and the time. These are medicines that I think of as being more for short-term use, ideally. Some patients may need them much longer term. But if can we figure out ways to carefully and, ideally with evidence, get them down on the lowest possible dose to maintain? If it’s a couple of times a week, that would be fantastic.

Christopher G. Bunick, MD, PhD: What you’re saying about patient and physician concerns made me think that this is why dermatologists got into dermatology: to care for patients, but with an emphasis on doctor-patient relationship. In terms of the counseling needed, it sounds like enhancing and embracing that patient-doctor relationship and communicating with your patients are going to be key.

Dr Stein Gold, what are some challenges, unmet needs, that you believe remain for atopic dermatitis?

Linda F. Stein Gold, MD: We’re in a wonderful time. I have the benefit of being a medical dermatologist, so I see patients in clinic. But I’m also a clinical investigator, so I’ve studied all these drugs in the clinical trials. I’ve gotten to watch them over many years. For many of these drugs, these are absolutely life altering. But 1 of the challenges and unmet needs is that not any 1 drug works for every patient. At this point, we can’t necessarily predict which 1 is going to work for any patient. We’re not where we are with psoriasis: if we’re getting PASI [Psoriasis Area and Severity Index] 100, who cares? It doesn’t matter; it’s going to work in just about everyone. But we’re not there yet. We’re getting there, but we’re not quite there. We still have a ways to go in getting all our patients with atopic dermatitis completely clear.

As was mentioned, we have FDA approval for the newer drugs, including 1 down to age 12. But a lot of our younger pediatric patients, even under age 2, have atopic dermatitis. The more we study these new medications, we’ll start to see those indications come down younger. And we’ll have the ability to get these patients under good control.

Christopher G. Bunick, MD, PhD: Dr Stein Gold, I really liked what you just said. What we’re moving toward in atopic dermatitis is similar to what we’re moving toward in psoriasis in the entire field of dermatology, and that’s pharmacogenomics. The improvement of precision molecular dermatology can really help us understand our patients. They may have atopic dermatitis, but what differentiates their specific type of atopic dermatitis? We can tailor their medicine precisely to that patient. I really think this idea of precision medicine that you bring up is going to be key to the progress in dermatology going forward.

Transcript edited for clarity.

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