Patient Journey and Presentations of Atopic Dermatitis


Dr Casey Butrus drives a discussion highlighting typical patient presentations of AD.

Casey Butrus, PharmD: Dr Cameron, describe different presentations of atopic dermatitis and how the management strategies differ for each presentation.

Michael Cameron, MD, FAAD: In the pediatric population, if you’re seeing classic infantile atopic dermatitis, which tends to present around 6 months of age, they can have a lot of rashes on their cheeks. They’re starting to teethe, and they’re feeding and getting a lot of saliva on their cheeks. They can have a lot of diaper dermatitis. For that management, it’s different from managing an adult. That comes down to a lot of hand-holding with the parents, like explaining bathing. A lot of times parents are bathing them too frequently. There are a lot of skin hygiene discussions before we even talk about treatment. That’s in the infant population.

As we move into the pediatric population, rashes tend to migrate from the cheeks, the diaper, and the scalp to that classic flexural predominance that we often talk about. As you enter adulthood, hand eczema becomes a real problem. Particularly with all the hand washing during the pandemic, we saw a ton of hand dermatitis. A lot of patients have always been atopic. Maybe they had eczema as a child and it went away, but then it presented in adulthood as eyelid dermatitis. These are all different manifestations of their atopy. How we’re going to manage it depends on where they present. We always try to talk about good skin hygiene, how you bathe, and things of that nature. But the therapeutic armamentarium that we’re going to utilize depends on their age, where it presents on their body, and things of that nature.

Casey Butrus, PharmD: You mentioned that the disease comes and goes for certain patients. Would you manage somebody who’s having a relapse differently from somebody who has chronic, consistent atopic dermatitis?

Michael Cameron, MD, FAAD: Certainly. If someone is having chronic, consistent atopic dermatitis, that’s a burden on them. If they’re failing topicals, then that’s when we start to have a discussion about systemic therapies. Fortunately for us, the treatment of atopic dermatitis has flourished in the last 10 years with all these new therapies. If someone that has chronic atopic dermatitis and we’re not fixing it, we’re going to have that discussion. If they have 1 acute flare-up, we have various options that we can do. It doesn’t have to be 1 of our chronic systemics. We can talk about phototherapy, prednisone, and things like that. It depends.

Casey Butrus, PharmD: We’ve noticed that atopic dermatitis can present differently for each patient. Amy, how do you navigate this patient journey with the patients you see on a daily basis?

Amy Brennan: That’s a great question. This is so nuanced. Every patient is different, and every case is different. The key in treating atopic dermatitis is meeting the patient where they are. For the therapies they need, we need to be able to target the insurance companies and access whichever medication the prescriber chooses, whether it’s a topical medication, a systemic, a biologic, or something else. We need to work within the practice to explain to the patient the expectations of those therapies, how we go about accessing those drugs, what the timeline looks like, what the protocols look like, what their responsibilities are for accessing those therapies, and what our responsibilities are in the office for accessing them.

Casey Butrus, PharmD: Dr Keegan, are there any differences from the physician perspective of managing the patient journey that you’d like to share?

Brian Keegan, MD, PhD: As both of you have said, it may depend where you’re meeting the patient in their journey. Some patients come in for the first time with an itchy spot and say, “What is this, and what am I going to do?” There may be a lot of education needed, and simple topical medicines may suffice. Other patients may have had a little experience along the way and met with a couple of physicians.

I meet other patients and they feel as if they’ve been through the wringer, saying, “I’ve seen many doctors, and no one really cares about what I have going on.” Or they come in with misinformation they found on the internet about what might help them. It takes time to unravel and help them understand their experiences and find the right treatment based on their experience, and to determine how to treat them over the long run.

Casey Butrus, PharmD: I want to bring up a point that Dr Cameron mentioned. The atopic dermatitis space has blossomed in the last year, specifically with new biologics and topical mechanisms of action coming to the market. However, with the innovation, there are increased costs associated with these medications and novel therapies. Amy, describe the clinical and economic impact of atopic dermatitis from not just the medication perspective but the whole patient experience.

Amy Brennan: There are many moving parts when you think about this process and all the individuals involved in it. It’s me as a patient advocate, it’s the prescriber, it’s the office staff, it’s the patients themselves, the payers, the insurance companies, the pharmacies, and specialty pharmacies when you get into specialty medications. All those things are so nuanced. That’s where insurance companies put in step therapies, prior authorizations, roadblocks, and things like that to try to limit costs for these more expensive medications. It’s key for us to come in and document the reason why the prescribers are choosing the medications they’re choosing and to target and access those drugs once they’re written.

Casey Butrus, PharmD: I agree. There’s a variety in the costs when you’re talking about topical corticosteroids. That may be pennies, but new biologics are thousands of dollars. There are a lot of direct costs associated with the medications, but those indirect costs from the health plan perspective sometimes get overlooked, like absenteeism and presenteeism, which is being at work and being able to do your job and be productive for your employer. We have employer groups from the health plan perspective, which is a big concern. If they’re paying for these medications for their patients, they want to make sure their employees are happy and their disease states are being managed well.

Amy Brennan: Exactly. It’s not just the visible costs, which are the ones we think about on a daily basis when the patients are coming into the office: paying for their office visits, paying for their prescriptions. There are many hidden costs, especially when you look at pediatric patients and caregivers giving care to that patient. That’s a time-consuming process, and it could cause them to miss work and that pediatric patient missing schooling. There’s a lot that goes into treating atopic dermatitis.

Transcript edited for clarity.

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