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Expert Perspectives in the Management of Pediatric Atopic Dermatitis - Episode 8

Advice for Curating an Atopic Dermatitis Treatment Plan

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Dr Peter A. Lio shares his advice for curating an atopic dermatitis treatment plan and explains the difference between rescue and maintenance treatments.

Raj Chovatiya, MD, PhD: I know that the master of the eczema action plan is Peter, so I’ll toss it to you. How do you try to simplify a lot of these concepts and the plans you put together for your patients?

Peter A. Lio, MD: It is hard. I am definitely guilty as charged for sometimes overwhelming patients with too many different things, too many different suggestions, and contributing to making it a part-time or even a full-time job. I have to kind of reign in my enthusiasm, and one of the things I think that can be so helpful is to do an action plan, to write it out. Even though many people do this, it’s remarkable that most of the patients I see, when I do my informal question, “Has anyone ever written it out for you before?” I would say the vast majority still say no. No one’s ever written it. So, just writing it down, it doesn’t have to be fancy. Have a very simple Microsoft Word template. Just literally typing it out is so empowering for the patient, and it focuses that discussion. Honestly, I don’t know what I would do without it. A lot of times, patients are saying, “OK, wait. I’m going to use what? What do I put on my face? So wait, that’s a cleanser? Do I leave that on?” I say, “Don’t worry, I’ll be right back. I’m going to step out, I’m going to print this out for you, and then we’re going to go through it together.” First of all, it’s nice because it gives me a minute to step out and take a breath, because usually it’s been an intense, sometimes 30 solid minutes of listening to this terrible story, and they’re very stressed and frustrated, so I say “Give me a minute.” I can compose myself and come back in, then they have this printout and they’re really focused on that.

Now, I also pair that with very specific product recommendations. I really believe that, and I respect people who don’t like this approach, I’ve had wonderful teachers who are better than me who didn’t give specific product recommendations, but I believe in it, and here’s why. Too many times, I’ll say, “Pick a gentle cleanser,” and they come back using something with exfoliating beads and fragrance. I’ll ask, “Why did you think this one?” They said, “Well, the person at the store said this one was great.” Or you say, “Pick a gentle moisturizer,” and you get the same kind of thing. So I like to be very prescriptive and say, “This is the one.” Even worse, if you just tell them the name, sometimes they get the wrong variant, or worst of all, they call you that night and say, “I can’t find it.” So, I even give them a link. I tell them this is where you can buy it online. You might find it elsewhere, I’m not saying you have to go through an online retailer, but I’m saying this is a backup. This is your backup so you know exactly the product I’m talking about, and exactly how much it is too. That also helps us anticipate the financial burden, something I’m also guilty of and I have to try to be really cognizant of. Because we know, even if it’s only $25 for this moisturizer, that’s a lot of money, especially nowadays. I think people are feeling really stretched, so adding all of these out-of-pocket costs can make it complicated.

Back to the key point though, writing out an action plan; I do it in 2 phases. What to do when you’re flaring up, that’s going to be your rescue, and then what to do once you’re better as maintenance plan. Ideally, we have the strong stuff when you’re flaring up for a short burst, and then when you’re better, ideally either no medicines at all or nonsteroidal-type prescriptions. Again, that’s where maybe the tacrolimus might come in, or even one of the newer agents, crisaborole. That’s great to help keep them at bay. Then always put on there that we’re going to follow up soon. I think the secret to atopic dermatitis is quick follow-ups, so almost always it’s going to be a month or two at most, and sometimes for a real severe patient I’ll say, “I want you to call me in 2 weeks. I want to hear how you’re doing because I expect you to be way better in 2 weeks.” This isn’t something where we need to say let’s check in 6 months to see how things are going. No way, I need them better in just a couple of weeks, and sometimes I will just do that as a phone call or an email.

Raj Chovatiya, MD, PhD: I think that it’s interesting. I do wonder that even though we’re in desperate need and we’re continuing to evolve our treatment options, if people just remembered the basics sometimes in terms of putting together that plan and remembering some of those nonpharmacologic approaches, and even simple approaches like topical steroids that have been around forever, you could probably make a huge dent in the disease and quality of life in our patients as long as we remember the fundamentals. That kind of ties me into thinking that historically, when you think about it, evolution has been relatively slow when it comes to atopic dermatitis therapy, but particularly slow in our pediatric population. There are obviously a lot of challenges when it comes to thinking about testing, conducting clinical trials, figuring out what works and doesn’t work. I understand some of those challenges, and it is really nice that we’re finally having options other than the mainstay of topical corticosteroids— which work, don’t get me wrong. They’re a super important part of therapy that we’re seeing now.

Transcript Edited for Clarity