According to the National Institutes of Health, atopic dermatitis (AD) affects nearly one-third of the US population.1 When properly diagnosed, most cases of AD are well-managed through basic first-line approaches such as appropriate bathing and moisturization practices and avoidance of triggers. Flares can often be successfully managed through reactive treatment with topical corticosteroids (TCSs), calcineurin inhibitors (TCIs), and PDE4 inhibitors.2

Patients with frequent flares may require a proactive approach to reduce relapse risk.3 “Proactive therapy is defined as the use of a topical anti-inflammatory agent usually twice a week for 2 consecutive days (weekend therapy) to previously affected areas of skin in combination with the daily, liberal use of moisturizers over entire body for an undefined but long-term period of time,” as explained in a review published in Clinical, Cosmetic and Investigational Dermatology.2 The agents generally recommended for this purpose are medium-potency TCSs or TCIs.4 This strategy “can decrease the frequency of AD flares while minimizing potential side effects typically associated with medium- or high-potency TCSs.”

For patients with moderate to severe AD who do not respond to these first-line approaches, second-line therapies including systemic medications and phototherapy may be warranted. Dermatology Advisor interviewed several experts to discuss treatment challenges and potential solutions in this patient population: Brian B. Johnson, MD, dermatology research fellow at the University of Rochester Medical Center in New York; Anthony Fernandez, MD, PhD, director of medical and inpatient dermatology at the Cleveland Clinic in Ohio; and Annie Grossberg, MD, assistant professor of dermatology and pediatrics at Johns Hopkins School of Medicine, Baltimore, Maryland.

Dermatology Advisor: What are some of the main challenges in treating moderate to severe refractory atopic dermatitis?

Brian Johnson, MD: To start, treatment compliance and managing expectations are 2 of the biggest challenges. Expecting patients to apply a cream or ointment as prescribed is often not realistic. They may be compliant with it at first, but as time goes on, compliance drops off. We think this is due to several reasons, including that the application of sometimes “greasy” topicals becomes too cumbersome to do daily — let alone 2 times per day as we often request — or they feel like they’re not seeing sufficient results, or their AD clears up.

Having a thorough discussion with your patients about what AD is; helping them understand that it is typically a chronic, relapsing-remitting disease due to a multitude of factors from a genetic and environmental standpoint; and educating them about the need for treatment compliance whether they are flaring or not can help with disease management.

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For patients with moderate to severe AD who do not respond to topical therapy, ideally, we would like to start them on dupilumab or phototherapy; however, there are challenges with both. With dupilumab, we’ve found that many insurance companies won’t approve the therapy if a patient has not tried and not responded to other systemic therapies or phototherapy. In addition, dupilumab is currently only approved for patients age ≥12 years, leaving younger patients without an easy option. For phototherapy, the challenges that we typically face are cost, lack of access (proximity to a phototherapy unit), and inconvenience due to the frequency of the visits and the length of time needed to see a good effect (6 to 8 weeks).

Patients who are not approved for dupilumab or are unable to be treated with phototherapy are typically treated with systemic immunosuppressants, which are all off-label uses and have their own challenges, including counseling on treatment adverse events and the importance of being compliant with lab monitoring. When patients do experience adverse events, you have to weigh the risks vs the benefits of keeping the patient on the medication.