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In a recent Dermatology Times Case-Based Roundtable custom event, “Beyond Steroids: Exploring Topical and Nonsteroidal Therapies for Atopic Dermatitis,” Robert Casquejo, PA-C, focused on real-world patient cases of atopic dermatitis (AD) in a conversation with fellow dermatology professionals. Casquejo and attendees explored the evolving treatment landscape, including systemic and topical therapies, as well as challenges in managing chronic and treatment-resistant cases.
The first case involved a 53-year-old male patient with chronic, untreated AD who had lived with the condition his entire life. The discussion centered on the varying morphology of AD depending on patient age, ethnicity, and disease chronicity or acuity.
A significant point of debate was whether the physical appearance of the disease should influence therapeutic decisions. The consensus was that chronicity, evidenced by lichenification and persistent lesions, often creates a need for systemic therapy.
Although some participants highlighted the effectiveness of newer topical medications—especially given their improved safety profiles compared with corticosteroids—the prevailing opinion was that patients with long-standing, refractory disease might benefit more from systemic treatment. “The consensus in the room was that this is a patient; once you start getting into chronic disease, even on a first visit, they are automatically thinking of systemic medication,” Casquejo said.
The discussion also touched on patient perception. Many clinicians felt that the patient’s frustration likely stemmed from years of inadequate treatment and an aversion to continuously applying ointments. This reinforced the importance of addressing patient fatigue when devising a management plan.
Another case involved a female patient, aged 62 years, with AD affecting her eyelids. Given the delicate nature of this area, participants immediately considered the limitations of corticosteroid therapy due to risks such as skin atrophy and glaucoma, particularly in patients with diabetes or preexisting ocular conditions.
“This is a slam dunk situation where novel topical medications have a distinct advantage because they do not carry the side effect profile, for instance, that a steroid does,” Casquejo noted. “[With] steroid use, really there [are] a ton of disadvantages. You can only use them for a short amount of time. You can’t use very potent ones, so that raises some problems.”
Novel nonsteroidal topical therapies were discussed as a clear advantage in such cases. Although calcineurin inhibitors have traditionally been an option, their common adverse effect of burning and stinging has been a drawback for many patients. Newer topical medications, such as Janus kinase (JAK) inhibitors and PDE4 inhibitors, appear to mitigate these issues while providing strong therapeutic effects.
The third case focused on a 33-year-old female patient with persistent pruritus who had failed multiple topical treatments. The discussion emphasized the importance of considering systemic therapy in such cases, particularly with the advent of targeted biologics and JAK inhibitors that offer novel mechanisms of action.
A key barrier identified in this case was insurance-imposed step therapy requirements. Many clinicians expressed frustration over the necessity to prescribe older treatments, such as topical steroids and calcineurin inhibitors, before gaining approval for newer, more effective therapies. The consensus was that patients already familiar with and having failed traditional treatments could more easily access novel therapies. However, treatment-naive patients often had to endure a trial-and-failure approach dictated by insurance requirements.
“There was an agreement that we’re in the day and age that vehicles may not be as relevant because [the] mechanism is making up for a lot of what vehicles may lack,” Casquejo said. “The efficacy, the mechanism by which they work, still carries a robust therapeutic effect, despite the fact that they are creams and not ointments.”
The panelists discussed 2 key scenarios:
As the therapeutic landscape changes, dermatology clinicians must balance efficacy, patient preference, and real-world limitations to optimize care for patients with AD, Casquejo emphasized.
