Best Practices in Managing Atopic Dermatitis in Skin of Color - Episode 7
Three experts emphasize the importance of setting expectations for AD treatment with patients.
Neal Bhatia, MD: The other part of the equation too is options when we get into efficacy and safety. Omar, is there anything about what we remember—with crisaborole ointment, pimecrolimus, and now dupilumab—from the efficacy and safety data that would apply to talking to skin-of-color patients or even pediatric patients?
Omar Noor, MD, FAAD: Setting the appropriate expectations for patients is very important. In skin-of-color patients, there’s a little distrust with medicine. A lot of times, there’s a lot of reasons for that. Obviously, it doesn’t apply to everyone. It starts with the clinical trials and some of the advertisements. In general, they may not feel that medications are necessarily made for them. I utilize crisaborole in certain situations, but there’s a risk of burning and stinging. Setting that appropriate expectation up front is very important because if a patient has an adverse reaction from a medication that we prescribe, we want to make sure they’re aware that it’s a possibility. For the majority of the patients in the clinical trial for crisaborole and in my practice, that tends to resolve within a couple of weeks.
I can tell patients that this is a possibility and try to treat through it. If it gets out of hand or you feel uncomfortable, give the office a call. Once they know that it’s a possibility, they can treat through it. For the majority of them, it improves over time. That level of burning and stinging isn’t necessarily seen in pimecrolimus, but we need to set appropriate expectations with pimecrolimus, which does have a black-box warning for lymphoma. As dermatologists, we know that black box is due to the clinical trials for the oral medication. That’s not something we necessarily saw in any of the clinical trials for Elidel [pimecrolimus] or something we’d be worried about with pimecrolimus. That said, we need to make sure patients are aware of the possibilities, make sure we’re playing a little defensively, right? If a patient googles “pimecrolimus” and we haven’t talked to them about it, then they’re going to come back to us and say, “Tell me everything about what you’re putting on my body or in my body.”
Neal Bhatia, MD: Right.
Omar Noor, MD, FAAD: That’s our responsibility about communicating that in our educated way. With dupilumab, we don’t have to worry about either of these things. There’s no burning and stinging. There’s a little injection-site reaction. I always tell every patient that that’s a possibility. We talk about conjunctivitis or any eye issues that are a possibility, but we don’t have to worry about any of the black boxes or the lymphoma we see with pimecrolimus.
Neal Bhatia, MD: Everything you said is pivotal to getting that information across. One thing I like to do, and you and I worked together in the crisaborole days, is have patients put it on unaffected skin. I say, “Does it sting and burn there?” They usually say no. I say, “That’s how it’s going to be in 3 days.” I always thought crisaborole should have been used at the first sign of flare rather than with things at their worst, but if you compound it with a little moisturizer, maybe it’s not so bad. Angela, Omar brought up the big point about the black box with pimecrolimus. What do you tell patients about the big, bad black box? Thirty grams of eating pimecrolimus isn’t going to happen.
Angela Lamb, MD: I tell them the same thing that Omar said. I know we’re here to talk about atopic dermatitis, but this is the same thing I say to my patients about topical retinoids if they’re breastfeeding. I say it can be very hard to extrapolate things to topical medications that are studied primarily on oral medications. I tell them the exact same thing, that this is more if you’re ingesting it. Unless somebody takes the bottle up to their mouth and sucks it out of the tube, like that old-school chewing gum. Unless they do that, you’re going to be good. But I love what Omar said about getting ahead of it. It’s not so much medicine. It’s trying to get ahead of and anticipate people’s concerns. That’s the craft and art of good doctors. It’s what separates the wheat from the chaff. If we’re able to get ahead of what people are going to call and ask about and give them confidence, that goes a long way and gives the doctor credibility that they know what they’re talking about.
Neal Bhatia, MD: Absolutely, and have a script. Everyone should have a bit of a script. It’s helpful.
Transcript Edited for Clarity