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Advances in AD Care
Advances in Improving Atopic Dermatitis Care

Released: August 08, 2023

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Key Takeaways
  • Novel therapies offer healthcare professionals (HCPs) several options to tailor therapy for patients with uncontrolled atopic dermatitis (AD).
  • Beyond clinical decision-making, HCPs can help improve AD outcomes by empowering adolescents to participate in their AD management and plan for future care transitions.
  • HCPs should strive to recognize and minimize the negative impact of social determinants of health to provide equitable and optimized AD care for all patients.

This commentary summarizes key takeaways on managing therapy of patients with uncontrolled atopic dermatitis (AD) presented during the Dermatology Intensive titled Taking Patient Care to the Next Level: Addressing the Clinical Challenges Impacting the Management of Dermatologic Conditions.

Choosing Therapies for Moderate to Severe AD in an Advancing Treatment Landscape
There are several therapies with new or updated FDA-approved indications for managing AD over the past several years, which are outlined in Table 1. Healthcare professionals (HCPs) should be ready and able to incorporate these into the care of patients who are ideal candidates for their use. There are several considerations that will aid HCPs in making the decisions with patients.

Ruxolitinib is a topical Janus kinase (JAK) inhibitor approved for treatment of mild to moderate AD. It is not likely to optimally address severe AD. Its use should also be limited to those with AD affecting 20% or less of their body surface area (BSA) and should not be used in excess of 60 grams per week or 100 grams every 2 weeks.

Two biologic agents, dupilumab and tralokinumab, are approved to treat moderate to severe AD. Dupilumab is an interleukin (IL)-4 and IL-13 inhibitor available as a subcutaneous injection every 2 to 4 weeks. It is indicated for use in patients as young as 6 months of age, which is the youngest age approved for novel agents. Tralokinumab, an IL-13 inhibitor, was more recently approved for moderate to severe AD and is also available as a subcutaneous injection via 2 prefilled syringes every 2 to 4 weeks. Although trials are ongoing for use in adolescent patients, tralokinumab is currently approved only for use in adults. These agents can be used in patients whose moderate to severe AD is not controlled with topical therapies, and can be used in combination with topical corticosteroids. Adverse events to consider include injection site reactions, ocular conditions, and upper respiratory tract infections.

There are also 2 oral JAK inhibitors, abrocitinib and upadacitinib, approved for once daily treatment of moderate to severe AD in patients 12 years of age or older. These agents can be used to treat AD if the condition has been refractory to treatment with other systemic agents, including biologic therapies. There are several boxed warnings to consider when evaluating safety, including increased risk of serious infections, malignancy, major adverse cardiovascular events, thrombosis, or all-cause mortality. These warnings were applied across the JAK inhibitor class in response to safety concerns in trials for rheumatoid arthritis. It is not yet clear if these risks are elevated in patients with AD; however, HCPs should certainly discuss these when developing treatment plans with patients in whom the risks may apply.

In summary, novel agents and those expected to emerge over the next few years offer HCPs many options when designing plans for AD management. In comparison to traditional systemic agents used off-label for AD, such as methotrexate, cyclosporine, or calcineurin inhibitors, these therapies also have more data to support efficacy and a more favorable safety profile. Considerations of patient preferences, disease severity and scope, and medical history will help guide choices.

Table 1:

 

Facilitating Improvements in Transitions of Care in AD Management
HCPs also need to intentionally plan for transitions of care for our patients with AD. This includes empowering young patients while they are adolescents. The philosophy of care in a pediatric practice can be much more hands-on and nurturing; guiding patients and caregivers without significant expectations for the patients to take responsibility for their own care. There is certainly a place for this approach, but along the way, strategies for transitions of care should also make room for more patient autonomy and involvement of adolescents in shared decision-making.

In addition, pediatric and adult care HCPs should collaborate and communicate regularly. Streamlined and productive communication between these teams is essential to ensuring patients receive optimal care and have a network to ensure their needs and priorities are addressed. Maintaining adequate care overlap and effective communication will ensure patients have an avenue for addressing any concerns they may have, especially if there are conflicts in therapeutic approaches between the teams.

It is imperative that discussions about the transition of care process start early and when appropriate for the patient. The European Academy of Allergy and Clinical Immunology has developed guidance (see Figure 1) recommending initial discussions about transitions of care when patients are between 11 and 13 years of age. Some dermatology programs won’t see patients older than age 16. HCPs need to make pediatric patients aware of that and structure an age-appropriate process of education and empowerment early enough to allow for growth over time. After transitioning into the adult care practice, support from the pediatric care team can last for a while, until 25 years of age or so, to really make sure that the patient is embedded into the new system of care.

Figure 1:

 

Recognizing and Addressing Healthcare Disparities in AD
Addressing healthcare disparities is another crucial topic in improving AD outcomes. It is so important to remember HCPs are treating patients and not just treating a disease in a textbook. HCPs can design the best therapy plan in the world, and if there are barriers to getting or using it, if the patient doesn't understand the key considerations of their AD care plan, or if care needs haven't been adequately explained, then the patient is not going to get better.

Although there are many important dimensions of social determinants of health to consider, this commentary can only address a few of those key for AD care. First, differences in clinical presentation and measurable outcomes in AD across racial and ethnic groups must be considered. For example, compared with White patients, Black patients are more likely to have AD with papular, follicular eruptions, less obvious erythema, and more significant components of postinflammatory hyperpigmentation. Asian patients with AD often have more clearly demarcated lesions that can appear psoriasiform, with more prominent scaling compared to White patients. A disregard of these considerations can result in delayed or misdiagnosis and inadequate or improper treatment. In addition, racial and ethnic minorities are more likely to have treatment resistant and more moderate to severe disease vs milder disease in White patients.

Luckily, there are some supports and strategies available for HCPs to consider and implement as appropriate. Some of these tools are reserved for addressing social determinants of health on a larger, systematic scale. This would include addressing gaps in clinician education, raising awareness, improving competency through continuing professional development for HCPs, and working with state and national partners to improve care throughout health systems. However, it is just as important to work to decrease disparities on an individual level. This can be accomplished by working to strengthen the patient–HCP relationship, mindfully increasing diversity and minority representation in practices, employing strategies to diversify representation in clinical trials, and so on.

Then from a practical perspective, HCPs should make sure each patient has appropriate access to care; sometimes that can mean expanding office hours to include nights and weekends, increasing appointment flexibility, offering high-quality telephone and virtual clinical services, and maintaining avenues for after-hour questions; these can all have a big impact on patient quality of life. For those with cost and coverage barriers, providing information (eg, verbal education or printed handouts on resources to decrease out-of-pocket expenses) or support (eg, staff who can help navigate prior authorization hurdles) for acquiring affordable, but evidence-based therapies can be incredibly helpful. HCPs should ensure they are also respecting patients as the expert on their own life, culture, body, and preferences. Viewing patients as key members of the shared decision-making team is crucial for building a rapport and meeting their individualized needs. For example, if a patient is concerned about a cultural bias or misunderstanding with their care team, strategies to navigate individualizing their care and including them in plan development can help to develop a plan that meets the goals of the team and the patient.

Your Thoughts?
What are your thoughts and questions on best practices in using novel agents for managing moderate to severe AD? Please answer the polling question and join the conversation by posting a comment in the discussion section below.

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