AD Case Study: Topical Steroids Are Not Cutting It

“We want to know about your decision-making process in terms of therapeutics for your [patients with] atopic dermatitis [AD], which topicals or systemics you choose, and how much patients’ insurances come into play” said Ted Lain, MD, MBA, board-certified dermatologist and chief medical officer at Sanova Dermatology in Austin, Texas.

Ted Lain, MD, MBA, moderated a discussion through solutions for challenging AD cases.

Lain moderated a Dermatology Times Case-Based Roundtable Meeting titled “Unraveling Complex Cases: Real-World Case Discussion on the Management of Atopic Dermatitis” in Austin. He shared cases with other dermatology clinicians and discussed strategies to optimize treatment sequencing, reevaluate long-term management, understand barriers to novel therapies, promote prior authorization integration, and diversify treatment areas.

Case Background

One of the cases discussed was a 28-year-old woman who presented with itching, discoloration, and dry skin patches on her lower legs and feet—characterized by lichenified skin. The patient’s sleep and clothing choices were affected by the itching. She had no family history of eczema, no history of significant medical conditions or surgeries, and no known drug allergies. The patient also had seasonal rhinitis, consumed alcohol occasionally, and was a nonsmoker.

The first symptoms started about 5 years ago; her primary care provider prescribed a regimen of topical corticosteroids and advised her to moisturize. The patient also noted that she had experienced new neck flares and thinning or atrophying skin in areas with repeated product use. During a particularly strong flare, she was prescribed a class 3 topical corticosteroid followed by a topical calcineurin inhibitor when the first drug had an inadequate response. Although the second treatment provided relief, there were still new flares, just not as strong as before. When asked about life changes, the patient mentioned she had a recent job promotion and a new work schedule.

Gaining Patient Trust

Roundtable participants discussed most relevant aspects of the case for treatment consideration. The clinicians noted that the patient had skin of color and normalizing the pigment was top of mind. Location on the lower legs was another key consideration.

“I think that the location in being a thicker area of the skin versus face or eyelids or something, you could maybe choose a higher potency steroid,” one participant said. “The challenge of this case would have been the chronicity of it and the frustration already with the steroid and wondering if you’re about to come out with 1 more steroid. Gaining her trust [is key].”

The roundtable participants talked about methods to gain trust, including learning what is most important to the patient: Controlling itch? Getting a good night’s sleep? Clearing the skin for optimal appearance? Participants agreed that the patient’s priorities help in developing a treatment plan. Since this patient was a young woman of childbearing age, she might be more concerned about appearance and the potential to get pregnant down the line, so asking about long- and short-term goals is critical, they said.

Creating a Treatment Plan

Occlusion therapy was brought up as an option to try 1 last method to improve the efficacy of topicals. Since the affected area was so large and thick, many roundtable attendees worried about the formulary issues and cost of nonsteroidals for the patient.

“I think they [patients] come to a specialist to find what’s the next step. So, some of these patients come with topical corticosteroid fatigue...What I often do is give samples of those nonsteroids that way you create a little rapport, or at least you’re entertaining the idea of a nonsteroidal,” another participant said as they described the start of their journey on the therapeutic ladder.

A few roundtable participants expressed the desire to jump right to ruxolitinib (Opzelura).

“Because if they [previous physicians] prescribed triamcinolone [for] her and that’s the only thing she had tried, I might want to try some other things. But in this case, the patient has tried 4 to 5, and that’s a pretty good college try with the steroids. It’s time to start thinking about something else,” they said.

Others added, “I would definitely mention the other options like the biologics that way if she says she’s heard of it and that’s what she wants, then we can move forward. And if not, she can at least kind of start looking into it and researching it. I like them to make a joint decision.”

Lain asked the roundtable how they felt about systemic options for this patient. Some were concerned about the black box warning for oral Janus kinase inhibitors. Some expressed gravitating toward dupilumab (Dupixent) since the patient has multiple areas of her body affected by AD.

Treatment and Insurance Considerations

The entire roundtable agreed that encouraging a patient to not get frustrated is essential to properly work through the AD treatment armamentarium. Some participants shared experiences with insurance companies if they jumped to a more advanced treatment or tried different biologics. One even shared their experience of writing a prescription for ruxolitinib. When it didn’t work for the patient, they, prescribed dupilumab. The dupilumab then was denied because the patient had already received a biologic.

Experts at the roundtable stressed the importance of advocating for patients and the need to try different treatments because AD has several complex factors that can impact the timing of flares and severity.