Considerations for managing mild-to-moderate versus moderate-to-severe atopic dermatitis and which therapies are appropriate in each setting.
Neal Jain, MD: One question that we all think about and we deal with every day is the management of mild to moderate disease and how is that different for patients who have mild to moderate disease vs moderate to severe disease. For me, 1 thing is whether this atopic dermatitis is on this spectrum and an individual patient can fluctuate from time to time. We have tools available. Many of us use or have seen the atopic dermatitis yardstick.
One thing that was imprinted on me during my training and that I still use these days is coming up with what I think of as the atopic dermatitis action plan. [This is] similar to an asthma action plan, where we say, “When you have mild to moderate disease, there’s foundational care that we want to think about, which is basic skin care: soaking baths, emollients, and topical steroids of low to mid potency to cool down acute flares. Or even using something like crisaborole [Eucrisa], which we mentioned a little earlier to help control a mild disease.
Depending on the response to therapy, [we may need to think] about stepping up therapy when we need to. That may include things like baths and other therapies like wet wraps before we start to go to more potent topical steroids, topical calcineurin inhibitors, or some of the newer agents. Having that sliding scale of options is 1 thing I think about when I’m managing mild to moderate patients vs moderate to severe patients, but I’m interested to know if you guys approach it in a different way. Dr Feldman?
Matt Feldman, MD: No, it’s a similar idea. When we discuss atopic dermatitis with our patients, even with mild disease, we’re educating them about the steps along the way. What would happen if there were a flare? What would be potential reasons for a more significant flare? How would we fight that flare? How do we prevent ourselves from getting to that point and using things like a yardstick? By having a written game plan, an action plan. By giving the patients tools to keep their disease under control. For a more mild to moderate disease, I may not get into the details of therapeutics that we’re going to get into more detail about in a moment. I discuss the fact that there are systemic agents available if we fight the good fight with some of these guidelines-based therapies from 5 to 10 years ago that are still relevant. Maybe if these patients progress to a more moderate to severe disease, we’ll have other options.
Introducing that there’s been a paradigm shift in how we treat atopic dermatitis, how we understand atopic dermatitis, gives patients hope that there’s a lot of therapeutic approaches out there and gives them a buy-in for an even more mild to moderate disease.
Neal Jain, MD: You mentioned earlier that as allergists we like to think about the things that might be provoking or contributing to a patient’s disease. We see more mild to moderate patients grounding ourselves and say, “What have you noticed?” I saw a child come in as we’re getting into our spring allergy season in Arizona. They say, “Other kids are getting their rhinitis, but he’s getting a flare of his eczema.” They ask, “What’s going on?”
We used to have to do the dirty work in our allergy clinics in fellows and tell the patient, “You’re allergic to your dog. You’ve got to do something about this.” Starting to say, “What are some things we can do from an avoidance standpoint” can help also.
Transcript edited for clarity.