A Case-Based Approach to Topical and Nonsteroidal AD Management

In a recent Dermatology Times Case-Based Roundtable event titled "Exploring Topical and Nonsteroidal: Atopic Dermatitis Management Approaches," Matthew Zirwas, MD, led a collaborative conversation for clinicians to explore challenging and complex cases regarding atopic dermatitis (AD) care. Zirwas, a board-certified dermatologist based at Bexley Dermatology in Columbus, Ohio, shared insights on differentiating between similar conditions and tailoring therapies for optimal patient outcomes.

Case #1: A 40-Year-Old Chemical Plant Operator with Chronic Hand Dermatitis

The first case involved a 40-year-old man with a 6-month history of hand eczema, possibly exacerbated by his recent work at a chemical plant. The dermatologists initially focused on differentiating between irritant, allergic, and endogenous causes of hand eczema, noting the importance of dorsal and palmar involvement. They emphasized taking a thorough history, including what the patient had already tried, how itchy vs irritated the rash was, and details about his work environment, especially glove reuse and application.

“We’re all very aware of the idea that if you occlude a pharmaceutical, it makes it more potent,” Zirwas said. “So…part of educating people about glove use is making sure that they don’t ever put the gloves on while their hands are not fully rinsed [of soap].”

The experts discussed the challenges of occupational contact dermatitis, where identifying the specific allergen at work is often less helpful than finding ways to minimize exposure. They also debated the value of patch testing in general, noting its high sensitivity but low specificity, and the difficulty of patient adherence.

“As somebody who did almost nothing but patch test for 15 years, my general experience was that they’re not that useful,” Zirwas said. “You hit some home runs, but it is the most miserable thing we do to patients.”

After this initial contact dermatitis diagnosis, the patient’s patch test came back negative, and treatment with topical corticosteroids provided only partial relief with frequent flare-ups. Because of this, the clinicians switched their diagnosis to AD.

The discussion then shifted to the limitations of topical steroids such as clobetasol, particularly their potential to impair barrier function with long-term use. They also touched on the role of paraffin wax baths in improving barrier function for irritant dermatitis, and the practical challenges of patient adherence.

As the patient is concerned about long-term steroid use, the clinicians discussed strategies on how to ease concerns and slowly introduce the idea of steroids in prior visits. The dermatologists settled on applying the systemic treatment of ruxolitinib (Opzelura; Incyte Corporation).

Case #2: A 32-Year-Old Office Worker with Worsening AD on Neck and Shoulders

The second case revolved around a 32-year-old female office worker who has had a history of AD since childhood but has noticed worsening on her neck and shoulders over the past year. Her body surface area is 7% and her Investigator's Global Assessment score is 4, and she has constant itch, sleep disturbance, and difficulty focusing on work. She also has asthma, which is well-controlled with a corticosteroid inhaler.

Zirwas and the panelists debated whether the rash was contact dermatitis or AD. Contact dermatitis from hair products was suspected, and hypoallergenic hair products were recommended. They also considered the patient’s asthma history, with some suggesting dupilumab as a potential treatment option if systemic therapy was pursued.

For initial treatment, the clinicians considered topical corticosteroids such as clobetasol, injections such as triamcinolone, or a topical calcineurin inhibitor (TCI) such as tacrolimus. Tacrolimus can cause burning, so they mentioned desoximetasone as a possible alternative.

When the TCI proved ineffective, the patient was started on upadacitinib (Rinvoq; AbbVie Inc). The dermatologists discussed the importance of providing context to patients on Janus kinase inhibitors, emphasizing the lack of increased risk despite the “scary-sounding” warnings on the box. Later, the patient switched to topical ruxolitinib in preference to oral medication and saw great results at the 3-month follow-up. The clinicians discussed its overall efficacy, with its rapid pharmacologic effect beginning in as little as 15 minutes.

“There’s nothing in the pipeline that is close to as fast or [that] overall has as much efficacy as ruxolitinib,” Zirwas said. It is as close as I think we will ever get to a perfect topical....It’s crazy that we’ve got a drug that works that well.”

Case #3: A 35-Year-Old Teacher with Persistent AD

The final case was that of a 35-year-old high school teacher with a scaly, itchy rash and open excoriations on his face, neck, hands, arms, and legs. The rash began 8 months prior during a stressful period involving home renovations and a difficult school semester; this caused sleep deprivation, affected his work, and made him self-conscious due to student reactions.

The patient’s excessive hygiene regimen included hydrocortisone cream 1% applied all over 3 to 4 times a day, calamine lotion for itch, nightly diphenhydramine which made him groggy during morning classes, and various “natural” moisturizers with lavender and citrus oils. The main challenge in this case was the patient’s resistance to changing his habits. The dermatologists discussed strategies for managing patients who use non–evidence-based products. The preferred approach was to consider the patient’s existing practices, acknowledging their perceived benefits, and suggesting ways to enhance their effectiveness.

“Use the word ‘boost.’ I learned that during my residency....There’s very little that patients like better than the word ‘boost,’” Zirwas advised.

The panelists noted the rash’s poorly demarcated appearance, suggesting AD rather than allergic contact dermatitis. They discussed the patient’s overuse of topical steroids, raising the topic of topical steroid withdrawal. To prevent rebound symptoms, the hydrocortisone cream was gradually tapered, and all irritating products were discontinued.

Initially, tacrolimus ointment, triamcinolone acetonide cream, and a daytime antihistamine were prescribed, with pimecrolimus added later. After 6 weeks, the patient had marked improvements, but he still noted persistent lesions, intermittent flares, and discomfort with the pimecrolimus cream. Ruxolitinib was prescribed twice daily, and he achieved improved itch, less visible dermatitis, and a reduction in flare-up.

Key Takeaways

• Nonsteroidal atopic dermatitis (AD) therapies are gaining attention due to their rapid effectiveness and ability to offer an alternative to long-term steroid use.
• A personalized and holistic approach to AD is vital for each patient, so address lifestyle and occupational factors, medical history, and potential treatment risks.
• When patients with AD are resistant to change, gradually offer evidence-based alternatives that can enhance their existing practices and improve overall adherence.