Topical and Systemic Agents to Manage Atopic Dermatitis


Andrew Alexis, MD, MPH, FAAD: Let’s discuss some of the innovations that we’ve seen over the past few years, very exciting innovations in the management of atopic dermatitis, starting with topical.

Candrice, why don’t you let us know about any new developments in topical therapy for atopic dermatitis?

Candrice Heath, MD: We have had topical corticosteroids for decades to treat atopic dermatitis, but there are also some newer medications as well that do not contain topical steroids. There is a medication called crisaborole. That’s the most recent topical. It’s a phosphodiesterase 4 inhibitor. It even acts in a different way from all the other medications we have. There also are some other older topical medications that do not contain steroids. One is called tacrolimus; the other, pimecrolimus. There are other choices besides topical steroids.

There are pediatricians or primary care docs or even some of my dermatology colleagues who take care of pediatric patients. I know some parents are very fearful of topical steroids. They’ve heard lots of bad things about them. It’s important to counsel your patients regardless of what method of treatment that you chose. Of course, as a dermatologist I have lots of patients who are using topical steroids. And I must let them know, yes, if you use this for a very long period of time, yes, there is a risk of skin thinning. But we’ll work together to try to prevent that from happening.

Also 1 of the myths, especially in skin of color that I had to talk about, is pigmentation changes. Often, topical steroids and topicals get blamed for causing pigmentation problems in patients with skin of color. But often, it is the atopic dermatitis itself, the inflammation associated with it, causing the pigmentation changes in the first place. This is definitely a topic that can be discussed with patients. And that’s something I enjoy talking to patients about as well. Those are some of the new topical things that do not contain topical steroids.

Andrew Alexis, MD, MPH, FAAD: I agree with everything you said, Candrice. But I will say that while there might me some anxiety in the provider and the patient community about hypo-pigmentation in corticosteroids, as you pointed out, oftentimes it’s just postinflammatory hypo-pigmentation. But steroid-induced hypo-pigmentation also occurs, particularly if you’re using class 1 or class 2 corticosteroids for an extended period of time. That remains a limitation of typical corticosteroids, that nonsteroid agents like crisaborole and tacrolimus and pimecrolimus overcome.

Candrice Heath, MD: Absolutely.

Andrew Alexis, MD, MPH, FAAD: What about systemic agents? We don’t necessarily use them as frequently. Thankfully, now we have other options. But they still might play a role in some instances.

Jamie, can you speak to the use of systemic agents for atopic dermatitis? Namely, the older systematics such as methotrexate, azathioprine, cyclosporine, which are used off-label for atopic dermatitis.

Jamie Weisman, MD: In cases of severe atopic dermatitis, I love these new topicals. I love the topical steroids. It’s interesting that we haven’t really talked about pityriasis alba, which is a mild form of atopic dermatitis that can present with hypo-pigmentation against infusing when we use steroids in those patients, because we’ve got light skin, and then we’re giving them a medicine that lightens their skin. But there are times when the topicals aren’t going to suffice or we need to try potent topical steroids, and we are going to run into problems. Or you give someone with deeply lichenified, thick, prurigo nodularis atopic dermatitis a tube of pimecrolimus, and we know that’s not going to work.

Sometimes we do have to bring out more potent agents. And I do use these agents. I tell my patients that with them, along with topical and oral corticosteroids, these are medicines that I can use to get you clear. Do I want to keep you clear? Certainly, with the oral steroids, I don’t want to keep you on those medications. And there are times when I will need to use what are called steroids, varying medications to keep you better. But they come at a cost. We must draw blood. We have to monitor for potential effects on the liver, on the kidney, with cyclosporine, for example. Those consequences can be irreversible. So these are more challenging medications to use.

On the other hand, I don’t want us to always shirk away from using them, because we’ve just been talking about how impactful the disease is. And if you have severe atopic dermatitis, sometimes it involves you basically head to toe. This can impact everything from your ability to date, get a job, sleep. You have no comfort from the moment you wake up until the moment you go to sleep. And we need to inform them; we have other options. Are they risk-free? No, they’re not. But can they be managed in a way that is safe? Yes. We can absolutely use them when it’s necessary to use them.

Andrew Alexis, MD, MPH, FAAD: Among those older systemics, do you have a lot of first-line agents that you consider for most of your patients with moderate to severe atopic dermatitis who aren’t responding to or who aren’t candidates for topical therapy?

Jamie Weisman, MD: We do have a biologic, which I’m sure we’re going to discuss later. Oftentimes I am thinking about a bridge to the biologic. In that case, it’s really severe. As a referral practice, I often get people who have been undertreated for so long that they wanted to be better yesterday. If that’s the case, I will reach for cyclosporine. In pediatric patients, I often use methotrexate. Children don’t drink alcohol, so that’s 1 of the limitations we have with methotrexate that we don’t in our pediatric population. I would say more of my patients are on the methotrexate, but if the severity is there, knowing that I have a bridge, I often reach for cyclosporine as a put-out-the-fire medication.

Transcript Edited for Clarity

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