Practical, Real-World Pearls for Managing Complex Atopic Dermatitis Cases

In a recent Dermatology Times Case-Based Roundtable event Lisa Weiss, MMSc, PA-C, offered practical pearls for 3 complex patient cases of atopic dermatitis (AD).

Asa physician associate practicing at the Dermatology & Skin Surgery Center in Stockbridge, Georgia, Weiss led fellow dermatology clinicians in an engaging discussion of real-world examples, best practices for treatment selection, and more.

The cases included a 27-year-old woman with a greater than 20% body surface area (BSA) and severe pruritus, a 36-year-old woman with 8% BSA and AD of worsening severity, and a 7-year-old boy with a 12% BSA and a history of AD since the age of 6 months.

Managing Expectations for Long-Term Therapy

Experts emphasized the importance of managing patient expectations regarding biologics for AD, particularly regarding chronic disease management. They noted that biologics can significantly improve symptoms but are not a cure. The discussion highlighted how treatment often evolves from frequent dosing to longer intervals, aiming for optimal symptom control with minimal medication. Pediatric patients were also discussed, with experts noting that although hope for remission exists, long-term symptom management remains the focus.

Attendees agreed that clinicians should inform patients that although newer treatments may offer significant relief, they may take time to show visible results, typically 4 to 6 weeks. Such discussion is particularly important for those who have experienced previous disappointments with therapies that failed to provide long-term relief.

Transitioning to Nonsteroidal Treatments

Attendees highlighted the transition from topical steroids to nonsteroidal treatments such as tapinarof (Vtama; Dermavant Sciences Inc) and roflumilast (Zoryve; Arcutis Biotherapeutics, Inc) as a crucial step in improving patient outcomes, particularly for those with persistent facial erythema. Experts discussed how these treatments offer effective symptom relief while reducing reliance on steroids, providing a safer, more sustainable option for long-term management.

Addressing Loss of Response to Dupilumab

The roundtable also explored strategies for patients who no longerrespond to dupilumab (Dupixent; Sanofi-aventis US LLC and Regeneron Pharmaceuticals, Inc), with experts noting the increasing availability of alternative treatments such as other biologics and Janus kinase (JAK) inhibitors. Although dupilumab remains a key option, clinicians discussed how they would consider switching therapies based on individual patient needs, with a preference for biologics before resorting to JAK inhibitors.

Pearls for Treatment Fatigue and Limited Relief Outcomes

Attendees discussed the importance of considering the individual’s quality of life and treatment goals when managing AD in adults. Clinicians should be mindful of patient concerns, such as treatment fatigue and hesitancy toward long-term steroid use, they noted. Educating patients about nonsteroidal options, such as topical immunomodulators, phosphodiesterase-4 inhibitors, and JAK inhibitors, is crucial for those who experience limited relief from traditional therapies or are concerned about steroid-related adverse effects.

Prioritizing Early, Aggressive Intervention

For clinicians managing moderate to severe AD, early intervention with potent topical treatments can help control symptoms before they become unmanageable. In one patient case, initiating higher-potency steroids early on in the treatment regimen allowed for quicker flare control. However, Weiss agreed it is essential to transition to nonsteroidal therapies as soon as possible to prevent the long-term risks associated with steroid use.

Balancing Outcomes With Impact on Pediatric Growth and Development

Weiss discussed the profound effect that chronic AD can have on a child’s growth and overall development. Persistent sleep disruption due to itch is not just a matter of discomfort; it has been shown to impact a child’s physical growth, she noted. When children, especially those with severe AD, suffer from poor sleep, this can lead to growth restrictions.

Clinicians should recognize the potential link between uncontrolled AD and growth impairment, educating parents that timely treatment of AD can improve both sleep quality and physical development.

Understanding the Emotional and Behavioral Toll on Children

In pediatric AD, clinicians must consider the emotional toll the condition has on both the child and the family, attendees agreed. Children with persistent AD not only deal with physical discomfort but also face emotional challenges, such as frustration, embarrassment, and social withdrawal. These can be exacerbated by sleep deprivation, leading to difficulties in school and social engagement and even causing behavioral problems.

For parents, the emotional burden can be overwhelming, especially when they feel their child is not receiving adequate relief. A key takeaway for clinicians is the need to address the broader emotional and psychological impact of AD on children, discussing how this can affect a child’s ability to focus, learn, and interact with peers. A comprehensive treatment plan that considers physical symptoms and mental well-being is essential.

Conclusion

The roundtable provided valuable insights into the complexities of managing AD, particularly in severe cases across different patient demographics. Key takeaways included the importance of setting realistic expectations for long-term biologic therapy, transitioning to nonsteroidal treatments to improve outcomes, and addressing the psychological toll that AD takes on patients, particularly children.

The expert-led discussion underscored the significance of personalized care, early intervention, and a balanced approach to treating the disease’s physical and emotional aspects.