Expert dermatologists review a final case about a 32-year-old male with AD, highlighting systemic therapy as first-line treatment.
Jonathan I Silverberg, MD, PhD, MPH: We have time to cover our last case and that is a 32-year-old male, so now we've gotten into the adult realm. He has had atopic dermatitis since school age which has worsened over the past 5 years. He’s experienced a lot of flare-ups in the past year that are getting better with the use of a lot of topical steroids and sometimes oral steroids, but then everything flares-up again within a few days; such a classic scenario of completing those treatments. He most recently was prescribed a round of oral steroids 4 weeks ago from an urgent care center, has to travel a lot for work as an attorney, and is not able to apply his topical medications as regularly as he should. Today's exam showed mild lesions covering approximately 10% body surface area. Impressions? What do you think? Mild, moderate, severe, topical, systemic? Go for it.
Brad Glick, DO, MPH, FAOCD: Well Dr. Blauvelt was mentioning before, BSA [body surface area] measurement isn't particularly our focus, but 10% is a fair amount of disease. Looking at this individual, this is clearly at least a moderate or moderate to severe individual. The challenges here really focus on activities of daily living. This is going to be an individual who's challenged a lot. He needs something fast, he needs something quick, and he needs something reasonably infrequent which has me starting to think about something injectable at least in my clinic, Dr. Swanson?
Elizabeth Swanson, MD: Same thoughts. He would benefit from a systemic therapy. Again, I'd probably talk to him about topical ruxolitinib just because it's a topical unlike what we've had before and for some people they'll use something like that. I would be talking to him about the systemic therapy options, biologics versus the JAKs.
Jonathan I Silverberg, MD, PhD, MPH: Thoughts?
Andrew Blauvelt, MD, MBA: I don't think it's been said yet, but the common reasoning is that patients don't like shots, they prefer pills. But for me taking a pill every day, which I do, also is less convenient than doing a shot twice a month. Two times a month where I have to remember to do something versus every day and I don't always remember to take my pills every day, so I just want to put that out there. A lot of times people say pills are convenient and I say really? I challenge that. This is a good one where we just ask him. You go through the pros and cons of each of them including shot versus pill, the speed, and the side effect profiles. This is a great one for the shared decision making.
Jonathan I Silverberg, MD, PhD, MPH: Implicit in yours is that this a systemic patient, this is beyond topical world?
Andrew Blauvelt, MD, MBA: Yeah, I think so.
Jonathan I Silverberg, MD, PhD, MPH: I completely agree. It's super important because in the case vignette, we're already highlighting the patient who went to urgent care and got prescribed oral steroids. We don't always ask, and this is a challenge in a busy setting, to get more information about what has happened in the past few months. A lot of times I use structured outcomes and patient reported outcomes in clinical practice and I'll ask the patient how they’re doing, and they'll say severe. I'm looking at their skin and it looks clear, why are they telling me they’re severe? Two weeks ago, the patient was in the urgent care and they prescribed doxycycline and prednisone. It's like oh, I forgot to ask that. In a busy setting we may fall into that trap, but it's so important to understand if they've done the multiple rounds of steroids and if they've done the topicals. I agree ruxolitinib can be important, but it's not going to replace multiple rounds of oral steroids. It's time to move on and maybe use it in conjunction, but then again, it's this shared decision making and you have to decide which way to do.
Andrew Blauvelt, MD, MBA: A key thing you just said is that the disease can go up and down quickly and so the day you're seeing the patient is not the whole story. In clinical trials too, you have patients you're seeing maybe every few months in the chronic phases. They may be sitting at 0 for months and a few days before they come in, they have a flare-up and then you're recording that score to be reflected over the last few months and it's not reflective - or the opposite where they're doing poorly, but on the day they come in they're doing well and that's the score you put. So, it's important to ask about the other days than the time you're seeing them.
Jonathan I Silverberg, MD, PhD, MPH: This is where the importance of shared decision making comes in because we've talked about with the other cases, for some speed is going to be super important, for some it's going to be the safety first, for some it's going to be the oral versus injectable. With the adults we have all the options on the table from the age indications, we don't always have those with the kids or not yet, so we've really got options. It's so important to review all of them. You highlight that at the beginning. You want to lay them all out, give them the landscape, let them decide based on what works for them. This has really been an incredibly helpful discussion, so I want to thank everyone for your outstanding comments. Thank you for watching this Dermatology Times Around the Practice. If you enjoyed the content, please subscribe to our e-newsletters to receive upcoming programs and other great content directly in your inbox.
Transcript edited for clarity