Audrey Dean discusses her experience of atopic dermatitis therapeutic side effects with her dermatologist, Jennifer Holman, MD, FAAD. Jennifer Holman goes on to highlight key pearls on managing patients with atopic dermatitis.
Jennifer Holman, MD, FAAD: Your therapy route is an interesting one, because it goes back several years where we were treating one part of your disease process and then we flipped because it was the atopic dermatitis [AD] that became the most problematic of all. Fortunately, the other stuff has stayed relatively quiet. But do you remember where you started on your therapy?
Audrey Dean: I know I was being treated for HS…. I know we had started on the injections and everything…and I feel like that’s when I noticed it flaring up again, I guess because those just weren’t the right medicines. They kind of flared up some other underlying stuff I had.
Jennifer Holman, MD, FAAD: You were on adalimumab for your [HS] for quite a while and it was during that process that looking back, doing our chart review that we started to see this pop up and then it was just it was almost this landslide. As that part got worse, it got worse and worse. And your [HS] was relatively well controlled. You had some flares here and there, and still do every once in a while. But you had topical [and regional] therapies we’ve done over the years for different things and different topicals. So, you’ve been on quite a few things to treat your skin disease over the years. I’m glad we’ve ended up where we have. You’re on upadacitinib right now. During all that history with any of these things, what adverse effects [AEs] of your treatments did you notice?
Audrey Dean: The main [AEs] I was really seeing—especially with the first injectables—was the psoriasis getting worse. I had [it] very mild before, but that’s when it all built up and was at its worst. It was during that time when I saw the worst [AEs] and it all coming in at once, basically.
Jennifer Holman, MD, FAAD: Initially, [it was] probably called psoriasis because it was a little bit of an unusual presentation for [AD]. It wasn’t until we really suppressed that arm that [suddenly] everything else announced itself as certainly not one that’s responding to a TNF or an IL-23 therapy. When I consider treatment options for patients, I typically go through this red light, green light, red light, yellow light, green light, especially with pediatric patients. That’s an easy way to think about it. We’ve got a great host of nonsterile topicals, as well. It used to be that we just give [patients] a tube of topical triamcinolone, clobetasol, or hydrocortisone…but I try to meet the patient where their disease needs are. If it’s super mild stuff that, every once in a while, they need a topical therapy, we can do that. I used to do a lot of light therapy or immunosuppressant therapy, but those come with burdens of blood work or the light therapy. You’ve got to come into the office 3 times a week, which [is also a burden] for a lot of [patients], especially [those who] live in a more rural population where…they drive an hour to the dentist office [and] 1.5 hours to see me at the dermatologist office. But now, as we’ve gotten further into systemic therapies, specifically like dupilumab or upadacitinib, we can really focus on systemically treating the quality-of-life issues for these patients. [We’re] not just clearing their skin with a tube of triamcinolone, but [we’re] focusing on itch [and] systemically getting these [patients] clear. My goal with a lot of these skin diseases is that I want my patients to be able to…not identify themselves as “I’m a person with [AD]” or “I’m a psoriatic.” [I want them to feel like] “Yes, I deal with that, but it’s completely managed and I don’t think about it as I go through my day because it doesn’t define who I am or the choices I have to make during the day.” Did you notice a whole lot of sleep disturbance when you were at your worst?
Audrey Dean: I wouldn’t say it was where I only got an hour of sleep at night or anything like that. Right before I [went] to bed, I [would feel] a little itchy, but after [approximately] 30 minutes or so, I was able to fall asleep. It wasn’t as bad as it could have been. It was quite mild.
Jennifer Holman, MD, FAAD: I always tell patients, “You itch at night because you’ve been busy all day long, working, then [suddenly] you stop and realize “Oh wait, I do itch.” Because you lay down and think about it…which is why I previously would do a lot of sedating therapies to treat itch and skin disease like this. [And that] gets risky when I’m treating [older] patients, because then they’re going to get up and go to the bathroom and [could] fall down in the middle of the night. So, having other therapies to treat itch, which is usually a barometer of the quality of life for our patients, is a big deal. But the decisions that I make for treating [AD]—body surface area [BSA] is part of it. We talk about over 10% [BSA], which you are definitely more than 10%. But I think both your facial and your scalp involvement—even if that had been the only thing that was involved—to me, that says, “Hello, we’ve got to treat you,” because that’s so socially impactful for someone young in the workforce. You’re working with patients all day long…. Same things in other skin diseases…. Is it disturbing their sleep? Am I seeing mental health issues? All of those [factors] kind of I come into the shared decision-making. If you remember, that was a conversation you and I had. I [said], “Hey, we’re not doing good and it’s time to go to something different.” It’s something that I think is key [for] both the patient and the physician. I may know exactly what I want you to do, but it’s important that you’ve bought into that plan [or] otherwise you’re going to leave and you’re not going to do it. And we’ve not been successful on either end of our part of our bargain. So, I focus both on treating the symptoms and the quality of life. But I am a dermatologist, so I do like to see clear skin as well. That’s always a side benefit. And by definition, we treat 3 flares. You had a flare recently, more with your HS than you did [with AD]. But all these inflammatory skin diseases—HS, psoriasis, [AD]—they wax and wane. To me, a flare does not mean that it’s a failure of therapy. It means we need to treat a flare—that happens. And for [those who] are not in Texas, it’s 107° right now at 6:00 on a Friday in Texas. So, anybody with any inflammatory skin condition—[AD], inverse psoriasis, HS—this has been a miserable summer. It’s been a mess. So, I expect some of these skin diseases to flare when we’re living above 100° for 30 days at a time. It’s just it’s part of that, but we treat through these flares.
Transcript was AI-generated and edited for clarity.