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Patient Case #1: AD Treatment Options


Elizabeth Swanson, MD; Brad Glick, DO, MPH, FAOCD; and Andrew Blauvelt, MD, MBA, highlight treatment options for a specific patient with AD, focusing on dupilumab.

Jonathan I. Silverberg, MD, PhD, MPH: In this particular case, based on age and the location of the rashes, what treatment options would you consider for this patient? Specifically?

Elizabeth Swanson, MD: I would boil it down to 3 choices: a standard routine consisting of a topical steroid with a nonsteroid for maintenance, the Aron Regimen as choice No. 2, and dupilumab as choice No. 3. But I look forward to a time when we have other topicals in this age group.

Brad Glick, DO, MPH, FAOCD: I couldn’t agree more. We’ve talked about other nonsteroidals. This is a mild to moderate case. We don’t want to minimize it. Some might say that it’s a severe case of atopic dermatitis because of the sleeplessness. This child is missing preschool, and that’s really impactful. I agree with the treatment regimen. Nowadays, I’m having clear conversations about biologic therapies with some of my parents too. I’ve used dupilumab, which is our only agent available in this space. Maybe we’ll get other biologics and oral systemic therapies. There might be some other possibilities. Maybe low-dose methotrexate. We could get a little more complicated if it’s more moderate and not a severe case per se. Those are the choices I’d make. I try to stay away from anything as complicated as methotrexate. Having dupilumab in this space and for this age makes it a very nice option.

Jonathan I. Silverberg, MD, PhD, MPH: I agree. In the modern era, I hope I never have to go back to methotrexate. The only time I’m ever turning to it is if I’m forced to by insurance. Otherwise, I’m not interested—not in adults, but certainly not in kids.

Andrew Blauvelt, MD, MBA: One thing that hasn’t been said yet that’s relevant to this case is that I don’t like mild, moderate, or severe to describe atopic dermatitis or psoriasis because in practice it’s always bifurcation. Is this a patient who’s a candidate for topical therapy? Is it a patient who’s a candidate for systemic therapy? That’s what we do with all our patients in dermatology. It doesn’t matter what disease. I’m going to go topical. Am I going to go systemic, or am I going to go both? That’s been helpful in psoriasis. We’re moving toward that and away from mild, moderate, or severe. That’s how I’m thinking about this patient. With 1 year of topicals and loss of sleep, this is clearly a patient who’s a candidate for systemic therapy. That’s my thinking. I encourage use of dupilumab knowing that I’m going to change the lives of this patient and their family. It’s going to take time to get that discussion going. I acknowledge that.

Jonathan I. Silverberg, MD, PhD, MPH: What’s your threshold? I agree completely, but how do you make that decision because that’s always mentioned that these patients are stuck in the topical world.

Andrew Blauvelt, MD, MBA: That’s a great question. I was involved in the new disease severity classification for psoriasis. It’s my statement that the International Psoriasis Council has adopted…. Widespread disease is clearly a candidate for systemic therapy. We’re keeping that in place, but the 2 added things are disease in special locations and failure of topical therapy. One of the criticisms of it has been that we didn’t define failure of topical therapy. We specifically didn’t because we think this is different for different patients and practitioners in different parts of the world. I resist defining it in both psoriasis and in atopic dermatitis. It’s where the art of medicine comes in. I’m looking at this patient. Have they given it a good go? I’m not going to put a number on it, but 1 year is pretty good. If it’s not helping this patient, this is a failure of topical therapy.

Jonathan I. Silverberg, MD, PhD, MPH: I agree, and I’ll raise you. I say 4 weeks because it’s hard to get them back that quickly for appointment. The data have shown that if they plateau in efficacy, they’re going to do well with the topicals, but there’s a difference between 50% better and 100% better. If they’re not in that 90% range, doing it for the next 11 months after that isn’t going to get them any better. If they get clear, then we’ll talk about maintenance and other things. But the decision is even quicker. I completely agree. To the audience, as you’ve heard: you’ve got to be careful not to let patients suffer in the topical realm. You may want to give 1 more try at a topical, but after they’ve gone on 2 topicals, move on. It’s time to step up.

Transcript edited for clarity

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