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Treatment for Mild to Moderate vs Moderate to Severe Atopic Dermatitis


Experts define stages of atopic dermatitis and share insight on the conventional treatment landscape for mild to moderate and moderate to severe atopic dermatitis.


Christopher G. Bunick, MD, PhD: Dr Stein Gold, I’m going to give you the wonderful task to talk about what are all the treatments dermatologists have been using for atopic dermatitis prior to the JAK [Janus kinase] inhibitors? Can you provide a historical overview of some of the conventional treatment options that dermatologists have been using for mild to moderate atopic dermatitis?

Linda F. Stein Gold, MD: Sure. I think it all starts really with a foundational approach to skin care. We can’t get away from the fact that we must really pay special attention to our skin every single day, and that means gentle cleansers, good moisturizers. We commonly use a soak-and-seal approach with our patients. We tell them, bathing is good. It used to be controversial, should I bathe, should I not bathe? You ask some doctors, and they might say, your primary care doctor might say no, only bathe twice a week, we don’t want to dry you out. But we kind of know that’s not necessarily true. As long as you soak, you bathe or shower, and then you seal straight away with a heavy moisturizer, that’s actually good for your skin, and that’s good for atopic dermatitis of all disease severities and it’s good all the time. So we want to cleanse the skin, hydrate the skin, and then seal it in with a really good, fragrance-free, good heavy moisturizer.

Then, when we look at our topical therapies, topical steroids really are the cornerstone of therapy, and they work. They work fast. We see rapid reduction of inflammation. But I really describe them as more of a short-term solution to a long-term problem because atopic dermatitis potentially lasts for many, many, many, many years or the majority of our patients’ lives, and topical steroids, especially the potent ones, are good for getting it under control fast, but it’s not a long-term solution. We do worry about the side effects of thinning of the skin. In skin of color, we know that steroids, especially potent ones, can take the color out of the skin, make it lighter. We can’t use potent steroids on skin in sensitive areas like the face or the skin folds, and we worry about atrophy over time.

Then, when we look at our nonsteroidal options, we have topical calcineurin inhibitors. What’s nice is they’re often a complement to topical steroids. Because they’re nonsteroid, we can use them anywhere on the body. We can use them on the face. We can use them on the skin folds. We know that they can be used also as maintenance therapy, getting that patient under control. We didn’t cure you, so often we want to have a short-term answer for flares and then a long-term solution for maintenance, and topical immunomodulators or topical calcineurin inhibitors are very good for that aspect. The nonsteroidal options sometimes sting, and we’ve kind of gotten used to that, especially with the calcineurin inhibitors. We do tell patients stinging and burning can certainly occur, especially initially.

Our other nonsteroidal option is a topical PDE4 [phosphodiesterase 4] inhibitor, crisaborole. That’s fortunately FDA [Food and Drug Administration] approved all the way down to 3 months. That’s wonderful because we have an option for those little ones that don’t have that many options. It’s an ointment formulation, we use it twice a day. It does sting a little bit as well, and it’s important for our patients, with any of these, is to say if you have some stinging and burning, that’s not necessarily an allergic reaction. Usually this goes away fairly rapidly. But as long as you warn patients upfront, it’s usually something that they can work with quite well.

Then, when we look at the systemic agents, they’re really reserved for more moderate or severe disease. Safety, especially when we use the broader immunosuppressants, can be a concern, and, of course, we have dupilumab [Dupixent] that was revolutionary for those patients with moderate to severe disease. But I think we have a lot of options. We need more options because no 1 agent gets everybody under control for an extended period of time. But I think we have some good tools in our toolbox, and we have some even better ones coming.

Christopher G. Bunick, MD, PhD: Absolutely. That’s wonderful. And certainly 1 of them, tralokinumab [Adtralza], to go with dupilumab. I really liked what you said about stinging and burning, especially parents of children, just so they know what to expect. I think it’s really valuable insight there. Dr Cohen, based on your clinical experience, how do you define moderate atopic dermatitis in patients, and what factors or treatment options seem to be important for their clinical care?

Jeffrey Cohen, MD: That’s a great question. And it’s important to try to figure out where on the spectrum of disease severity your atopic dermatitis patients sit because that helps you talk with them about what they can expect and think about how you may want to treat them. To me, the moderate atopic dermatitis patient is the patient who has consistent skin disease, not necessarily 100% of the time, but much of the time does have some area of activity.

Often these areas are confined to 1 area, you can define where it is, you can think about where it is. It’s not that they have head-to-toe involvement or huge amounts of their body involved at any 1 time. These patients have itch. They may not have itch every day, all the time, but they do have itch that is present enough to disrupt their functioning and make it difficult for them to do the things that they want to do on a daily basis. Likewise, their sleep may not be disrupted every single day, but is often enough disrupted that it disrupts their life and their life functioning.

Dr Lio made a very nice comment about how it’s very hard to really measure all of these things, especially in the confines of a clinical visit where you’re trying to assess the skin and decide on a treatment and also figure out how the atopic dermatitis really impacts someone’s day-to-day functioning. But that’s sort of the way that I think about a moderate atopic dermatitis patient. These patients, like all patients, exist on a spectrum. Some of them are able to use topical steroids for short periods of time here and there to manage their disease flares, and then otherwise [they] can use gentle skin care to keep themselves under control much of the time.

Others need to use something all the time, alternating between topical steroids and some of the other nonsteroid options that Dr Stein Gold just reviewed. Some of these patients, however, do need a more systemic treatment, and some of them are candidates for treatments like dupilumab, and then also now more recently some of the newer JAK inhibitor creams or even systemic JAK inhibitors that we use as we get to the more severe end of the moderate end of the spectrum.

Phototherapy can also sometimes be helpful for these patients, too, if they don’t want to use a systemic option and don’t respond well enough or adequately enough to topical medication. So there’s a wide range of treatments that can help these patients and it really depends on how much the atopic dermatitis impacts their overall daily functioning.

Christopher G. Bunick, MD, PhD: Excellent. That’s a wonderful segue into our second segment, which is going to focus on the new therapies that Dr Stein Gold and you have just mentioned are so important to continuing to innovate in the field of atopic dermatitis.

Transcript edited for clarity.

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