Navigating a Long-Term Journey: From Topicals to Systemic Therapies in AD

Kristine Kucera, MPAS, PA-C, DHS, and Mickey Bryson

In the recent Dermatology Times Patient Perspective custom video series “Understanding the Atopic Dermatitis Patient Journey,” Kristine Kucera, MPAS, PA-C, DHS, was joined by one of her patients, Mickey Bryson, in sharing Bryson’s difficult and long journey to achieve relief from atopic dermatitis.

Kucera, a board-certified physician assistant at Bare Dermatology and an adjunct assistant professor at the University of North Texas Health Science Center in Dallas, Texas, described when she met Bryson in September 2016. Bryson came to see Kucera with a persistent, itchy rash. Bryson previously had seen another clinician and was prescribed clobetasol ointment twice a day for 1 month. Bryson’s atopic dermatitis appeared on his knees and ankles and constantly itched. While using clobetasol ointment, Bryson noted that he experienced some relief, but nothing long term, and the itching remained.

First Impressions

When treating a patient with atopic dermatitis, Kucera initially addresses itch—specifically, itch intensity. Kucera stressed the importance of addressing severe itch right away, especially if it’s affecting the patient’s sleep and quality of life. During Bryson’s first appointment, Kucera noticed numerous red patches that had been scratched and had significant skin involvement.

“I knew when I saw you that we needed to do something systemic, not just something topical. Anytime we have any skin eruption like this, whether it be atopic dermatitis or psoriasis, we know that there’s an inflammatory component that’s internal. My mind immediately goes to, ‘We need to turn off the problem. We need to get to the root of the cause. We need to turn off the inflammation inside,’ ” Kucera said.

Bryson’s Journey

Apremilast

After Bryson had a short period of relief from using clobetasol cream and an internal prednisone taper, Kucera prescribed apremilast (Otezla; Amgen). According to Kucera, she chose apremilast because it is FDA-approved for psoriasis and psoriatic arthritis. Bryson’s atopic dermatitis presented as psoriasiform dermatitis, and Kucera had seen apremilast work for previous patients with a mix of psoriasis and psoriasiform dermatitis. Again, Bryson experienced relief that did not last.

Secukinumab

After realizing Bryson’s atopic dermatitis was not improving, Kucera considered secukinumab (Cosentyx; Novartis), an IL-17 inhibitor. At that time (October 2017), IL-23, JAK, and TYK2 inhibitors were not available. Kucera chose secukinumab for its fast onset.

With secukinumab, Kucera felt it was important to check in with Bryson about how he felt about changing from an oral pill to a self-injected treatment.

“It is quite challenging to give yourself an injection, but after a few days or weeks of doing it, then it pretty much became routine,” Bryson said.

Despite not minding the injections at first, Bryson admitted to Kucera that he had concerns about the long-term effects. Kucera emphasized that trust is a major component of the relationship between patient and clinician, and she appreciated that Bryson felt comfortable enough to share he was concerned.

Brodalumab

After still not achieving complete skin clearance or itch improvement, Kucera moved on to therapeutics with higher clearance rates and chose brodalumab (Siliq; Valeant Pharmaceuticals), another IL-17 inhibitor.

Brodalumab is FDA-approved for psoriasis, and according to Kucera, she still believed at this point in Bryson’s treatment (March 2018) that he had a cross between atopic dermatitis and psoriasis.

Bryson felt frustrated as he progressed through therapeutics that didn’t provide complete relief. While on brodalumab, Bryson never achieved full clearance and experienced a small flare. Kucera treated the flare with prednisone, which provided some relief.

“There has to be something else that can give him relief. If the prednisone is doing it, and the brodalumab is not, that means there’s an inflammatory component inside that we can control,” Kucera said.

Upadacitinib

In January 2023, Kucera discussed a newer therapeutic with Bryson, upadacitinib (Rinvoq; AbbVie). At that time, upadacitinib was one of the few FDA-approved treatments specifically for atopic dermatitis that Kucera had seen work well in patients.

Kucera reviewed the risks and benefits of upadacitinib with Bryson, who admitted he was looking forward to an oral pill again after using self-injections. Another benefit Kucera discussed with Bryson was the potential for rapid itch clearance.

“It did work very quickly for me. The itching went away in a matter of 48 to 54 hours; it was that quick,” Bryson said.

Now, Bryson is taking upadacitinib15 mg, the initial starting dose, every day and has not had to increase his dose. Additionally, not only did Bryson’s itching subside almost immediately, but he also achieved complete skin clearance.

Based on Bryson’s previous concerns, Kucera asked if he had hesitations about the long-term effects of upadacitinib. Bryson said that as a patient he is not familiar with long-term studies or data, but that if upadacitinib keeps him “clear and happy,” he is not concerned.

“The good news is that all the pharmaceutical companies these days do long-term efficacy and safety studies on all their medications that are out now. So we have some really long-term, great data,” Kucera said.

“I do appreciate you and your staff. You did what you could do with what you had available at the time. You educated me along the way, we worked as a team, and it worked out for the best,” Bryson concluded.