Dr Grossberg: Taking time for patient and family education on various management techniques, such as soak and smear and the use of the wet pajamas technique, can have a huge impact on families’ compliance. The topical regimens that are necessary to improve moderate-to-severe refractory AD are often time-consuming and can be confusing at first since several steps are involved. Keeping the regimen as simple and straightforward as possible is important. Providing detailed and individualized handouts so that families have step-by-step instructionst tends to be helpful.
Having a nurse is available to review a complicated regimen with the patient and their family immediately following the physician’s visit to help consolidate information and answer any additional questions can also considerably improve the understanding of the regimen and patient compliance. In addition to patient education, clinicians should be abreast of the most up-to-date approved therapies for AD in patients of all ages and consider initiation of systemic therapy for disease that is refractory to an aggressive topical approach.
Dermatology Advisor: What are the remaining needs in this area in terms of research, physician or patient education, or otherwise?
Dr Johnson: I believe that there is a lot of great research currently evaluating new targets for the treatment of patients with mild to severe AD. [Editor’s note: Various monoclonal antibodies, JAK inhibitors, and other therapies have shown promise in treating AD and are currently in Phase III clinical trials.2] If these therapies prove to be effective and receive FDA approval, I believe that we will be able to create a more individualized approach to treating refractory AD.
With that being said, I do believe there is a need for research on why certain patients respond to specific therapies and others do not; in other words, to move closer to the reality of personalized medicine. For instance, why do some patients respond well to dupilumab, while others show great response initially then relapse, and still others do now have any response at all? I believe that having this information will allow us to more effectively and efficiently treat patients with AD of all ages and levels of severity.
Dr Fernandez: A tremendous amount of work still needs to be done in the AD arena. In terms of educating patients and clinicians, it would be valuable to be aware of some of the points I touched on, such as the role of bacteria and allergic contact dermatitis in disease activity. Also, helping physicians understand the quality-of-life impact of AD on patients and their families can help to ensure that they take this condition seriously.
It is also important to educate patients and physicians that emerging evidence suggests that moderate to severe AD is a systemic disease, much like psoriasis and hidradenitis suppurativa. This can underscore for patients the importance of adequately treating their disease and prompt physicians to screen for pertinent comorbid diseases these patients are at risk for developing.
In terms of research, we still need a better understanding of disease pathogenesis, particularly the role of the microbiome and environmental exposures. In addition, we need to better understand the different subtypes of AD. For example, adult-onset AD accounts for up to approximately 25% of all adult patients with AD, and clinical features seem different than in adults who have had AD since childhood.
Finally, we need better treatments for moderate to severe AD. Dupilumab has been a welcome addition to the therapeutic armamentarium, but there is definitely a need for additional medications. Luckily, there are currently numerous clinical trials investigating novel medications that hopefully will be effective and available for use in our patients sometime in the future.
Dr Grossberg: More research is needed that explores the safety and efficacy of new systemic medications in AD, particularly in children. Dupilumab was the first biologic agent approved for adults and adolescents 12 and older with AD. As of now, more research is needed to explore its safety and efficacy in younger children. Additional research is also needed regarding the development of newer biologic agents for the treatment of refractory moderate to severe AD in both children and adults.
1. National Institutes of Health, National Institute of Allergy and Infectious Diseases. Eczema (atopic dermatitis). www.niaid.nih.gov/diseases-conditions/eczema-atopic-dermatitis. Accessed June 5, 2019.
2. Johnson BB, Franco AI, Beck LA, Prezzano JC. Treatment-resistant atopic dermatitis: challenges and solutions. Clin Cosmet Investig Dermatol. 2019;12:181-192.
3. Berth-Jones J, Damstra RJ, Golsch S, et al. Twice weekly fluticasone propionate added to emollient maintenance treatment to reduce risk of relapse in atopic dermatitis: randomised, double blind, parallel group study. BMJ. 2003;326(7403):1367.
4. Kapur S, Watson W, Carr S. Atopic dermatitis. Allergy Asthma Clin immunol. 2018;14(Suppl 2):52.