Role of Guidelines and Shared-Decision Making in Atopic Dermatitis


A panel of experts discuss role of guidelines and importance of shared-decision making in managing patients with atopic dermatitis.


Matt Feldman, MD: In our next portion of our discussion, we’re going to enter I think the more exciting parts of this that we all enjoy now as providers, is treatment.

I think a lot of these more severe atopic dermatitis patients that we’ve shared some anecdotes about already in the conversation we didn’t have as many tools in the toolbox that I think we felt as comfortable with as we do now.

Before we get into some of the more cutting-edge therapies that we can use, I would love for the group to have a conversation about the American Academy of Dermatology guidelines and/or if those guidelines play a large role in how you approach your patients, specifically lifestyle changes.

There are discussions about bathing, wet wraps, frequency of bathing, soaps that are used, etc. Do you lean into those guidelines? Do you cherry-pick if you only like some of the suggestions?

I always like to call guidelines, not rule lines. They’re an option to follow, but they’re certainly not the rule, so I’d love to hear the experts in the panel, your opinions on this.

Marc Serota, MD: I think it’s important that we reexamine the point in time in which we present systemic therapies as an option to patients.

Historically, when all we had was traditional immunosuppressives, we would do everything we could to not put patients on systemic therapies because of their relatively poor safety profile.

Since we’ve had newer developments in systemic therapies, we have therapies that are not what we would call immunosuppressives and we have therapies that are FDA [Food and Drug Administration]-approved for moderate and severe atopic dermatitis. We have to reset our minds when we actually present the options of systemic therapies.

I think it’s our job, especially as specialists, that when patients come to our office, that they hear all the different treatment options so that they can feel empowered so that they have shared decision-making and so when we do recommend these therapies, they have a chance to research them on their own and understand what those therapies do and why they might benefit their condition.

I think it’s very important that we discuss systemic therapies with patients. Most of the time, if they have moderate or severe atopic dermatitis, I’m doing that at our very first visit. The way I explain it is I say we have management for acute flares which would be your topical therapies. Then we say, well, what are we going to do to control your disease that you never need those emergency medicines that you’re never having flares?

Those could be systemic options. It can also be lifestyle changes like bathing habits, their daily use items, like making sure they’re using good barrier protection on their skin. All these different things can help, but I think it’s important to make sure you lay out all the treatment options so that patients have some shared decision-making about what treatment option they want to consider.

It kind of goes back to that, find out what the movie looks like scenario. Sometimes you don’t think they’re very severe, but once you explain the systemic option, patients much prefer that to using topical therapies all the time.

It can be very difficult or messy and it’s not convenient for the patient so there are a lot of reasons they might want to consider systemic therapy as long as they know that they are options.

Matt Feldman, MD: I agree with you, Dr Serota. I’d love to hear what the others think about what you’ve said. I would also say, well, we should be framing these new therapeutics that are systemic, educating our patients about them, framing them in the right situation.

I certainly think we’ve all had our anecdotal patient or 2 where we do lean into some of those topical therapies. We do discuss some of the exacerbating factors that may be contributing to poor control whether that be a skin infection, whether that be concurrent irritants, and really do turn the corner with these patients.

I want to hear your thoughts on how you balance these excellent new systemic therapies that I think many of our patients need to be considered for, but also some of the old guidelines that we did lean into a little bit in the past, and maybe we did have some success with from time to time with our patients.

Neal Jain, MD: I would agree entirely with that comment. We have, as you said Dr Feldman and Dr Serota, have had all these different tools and I think one of the purposes of these guidelines is really to lay out the tools that are available to us.

Ranging from the different topicals, whether they be topical corticosteroids, topical anti-inflammatories, topical calcineurin inhibitors, but also simple, tried-and-true practices including bathing, soak and seal, soak and smear, and the use of emollients, which can be highly effective.

I think when we start to talk about some of the therapies later, and if you really examine some of the studies, you can see how effective even mid topical steroids and the use of emollients can be when you look at the placebo arm for some of these studies.

I think it is a shared decision-making process where you talk with families, and you sort of gauge, what have you done? What haven’t you done? What have you tried, what’s been successful and what hasn’t been successful? Why? Is it because it’s too time-intensive? Is it because you haven’t been able to afford the therapies?

I think those are all things that play into our decisions when we have our conversations with our patients about where am I going to go with this patient. I think it also takes, especially when we see those more severe patients, sort of some buy-in and education about what’s going on, addressing what are the factors that are triggering this. Do you even have access to the ability to take a shower every day and to put an emollient on because you can’t afford them, or you can afford them?

I think that they are guidelines. As you said, it’s a roadmap, it’s not a rule book, but it is at least a starting point, and it sets the stage for us to start to think about how are we going to approach these patients?

Peter A. Lio, MD: I couldn’t agree more. I would just add one of the hardest parts, but it’s for a wonderful reason, we finally had all this innovation, all these new treatments that our guidelines from 2014 are really outdated so we are in dire need of some updates.

It’s fascinating. Of course, this year, in 2022, we have a flurry of new things and there’s more in the pipeline so it’s getting more and more difficult to figure out how should we be placing these things. Of course, people are asking us, we’re seeing a lot of hard cases and it’s like, where do you start to bring this? Dr Serota pointed out, where do you bring in these systemic agents?

The answer is it’s changing. One of the fascinating things that I love to follow is the idea, I call it the virtuous cycle of drug development, as we get new and better drugs, then the treatment to target the disease changes. Now we can offer more.

It has this cool feedback loop of saying now in the old days, we might say, “Well, you’re going to have to kind of tough it out, or you might have to live with this.” But now we can say, we have a few more things we can offer. We haven’t exhausted everything like we used to.

Transcript edited for clarity.

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