Management of Atopic Dermatitis With Hand and Foot Involvement

In a recent Dermatology Times Case-Based Peer Perspective custom video series, “Optimizing Outcomes in Atopic Dermatitis: Therapeutic Approaches for Hands and Feet,” Alexandra Golant, MD, an assistant clinical professor at Icahn School of Medicine at Mount Sinai and medical director of the Dermatology Faculty Practice and program director of the Dermatology Residency Program at Mount Sinai in New York, New York, delved into the complexities of managing atopic dermatitis (AD) with a particular focus on hand and foot involvement. This condition can significantly impact patients’ quality of life, even if the affected body surface area is relatively small. Golant emphasized various therapeutic approaches and practical considerations for treating these patients.

Prevalence and Impact

Golant noted that patients with hand and foot AD can suffer year-round or experience seasonal flares, particularly during colder or drier months. Interestingly, she said there has been an uptick in hand involvement post COVID-19, likely due to increased handwashing and sanitizer use. Individuals who have frequent contact with water, such as health care professionals, hairdressers, and those caring for young children, see higher prevalence rates. “Hands are really how we interact with the world,” Golant pointed out, highlighting the substantial impact of hand AD on daily life.

Pathophysiology and Barrier Dysfunction

Understanding barrier dysfunction is crucial in AD’s pathogenesis. Patients with AD have inherent barrier dysfunction and a skewed inflammatory response. This is particularly problematic for hands and feet, which frequently make contact with potential irritants and allergens. “You’re dealing with a patient population that genetically has an impaired skin barrier,” explained Golant.

Treatment Approaches

For mild AD, better skin care practices, such as using thick creams or emollient moisturizers, can suffice. However, moderate to severe cases often require additional treatments. “My approach generally to the topical management of AD is making sure these treatment recommendations are practical for patients,” Golant said. For instance, greasy ointments may not be practical for those who use their hands extensively to drive, complete manual labor, or interact with others.

Systemic Therapies

Golant discussed the criteria for considering systemic therapies. Patients with hand and foot involvement often fit the profile of having moderate AD due to high-impact areas affecting their quality of life. According to the International Eczema Council, having less than 10% of the body surface area affected but with high-impact areas such as hands and feet qualifies as moderate AD. “It’s a great example of a patient with low body surface area of involvement but high impact on quality of life who can be a great candidate to start a systemic form [of treatment],” she noted.

Efficacy of Systemic Treatments

In her practice, Golant has observed that patients with hand and foot AD often respond exceptionally well to systemic treatments. She said, “I have seen incredible rapid disease control, clearance, and significant itch reduction very early on after starting systemic agents.” These patients often experience relief faster in the hands and feet than other body parts, she noted.

Available Systemic Options

The current systemic options for AD include biologics and Janus kinase (JAK) inhibitors. Dupilumab (Dupixent) and tralokinumab (Adbry) target IL-4 and IL-13 pathways, while abrocitinib (Cibinqo) and upadacitinib (Rinvoq) are JAK1 inhibitors. Golant noted, “The order in which you use them or how you approach patient selection is so individual for each provider.” Earlier this year, results from the LIBERTY-AD-HAFT clinical trial (NCT04417894) showed consistent rates of clearance in hand and foot AD with dupilumab.

Quality of Life as a Guiding Principle

Quality of life remains a critical factor in treatment decisions. Golant recounted patient experiences to underscore the profound impact of hand and foot AD. “I have had patients recently tell me things like ‘I would cry every night in anticipation of bedtime because the itching on my hands is so significant,’” she shared. These insights drive her to tailor treatments to individual needs and lifestyles.

Case Study

Golant presented the case of a 38-year-old construction worker with moderate AD diagnosed at age 15. Despite using various treatments, his symptoms persisted, impacting his job performance. This case exemplified the struggle of patients with AD with significant quality-of-life implications despite minimal body surface involvement. Golant noted, “We like to see patients…as early as possible…after a diagnosis of AD, particularly when they are not having an adequate response to first-line therapies.”

Appropriate Use of Topicals

Golant stressed the importance of using topical steroids appropriately. “I would argue [that a steroid] of any potency is not appropriate for daily use. It shouldn’t be used as a moisturizer,” she asserted. Instead, she advocates for a comprehensive assessment to identify patients who may benefit from systemic treatments after exhausting topical options.

Future Conversations and Hope

Golant advised setting realistic expectations and providing hope for patients considering systemic treatments. “I like to mention the whole cascade of treatment options at that initial visit so the patient really can be empowered to make a treatment decision that they feel is best for their particular scenario,” she explained.

Conclusions

Golant emphasized the need for individualized treatment plans that take the patient’s lifestyle and disease impact into consideration. With advancements in therapy, she remains optimistic about the ability to offer significant relief to patients with AD. “In 2024, we have incredible treatment options for atopic dermatitis,” she concluded, highlighting the importance of a patient-centered approach in managing this challenging condition.