Clinical Insights Into Challenging Atopic Dermatitis Cases: Part 2

In a series of Dermatology Times Case-Based Roundtable® events, leading dermatologists and their local peers tackled some of the most challenging cases of atopic dermatitis (AD). These gatherings provided an invaluable platform for collaborative discussion, innovative problem-solving, and the exchange of cutting-edge treatment strategies. Each session featured in-depth case presentations, allowing participants to delve into the complexities of atypical AD presentations and explore various diagnostic and therapeutic approaches. These clinical insights from Ohio, Connecticut, and New Hampshire showcased the dermatology community’s collective expertise and dedication to improving patient care.

Read part 1 featuring Matthew Zirwas, MD.

New Haven, Connecticut

Mona Shahriari, MD, FAAD, an assistant clinical professor of dermatology at Yale University School of Medicine and associate director of clinical trials at Central Connecticut Dermatology Research, hosted a Case-Based Roundtable discussion in New Haven.

Case 1: Adolescent Female With Severe Itch Impacting Sleep

The first case concerned a girl aged 12 years with an intensely itchy rash, primarily in the bilateral, antecubital, and popliteal fossae. She had a history of AD since birth; it recently started affecting her sleep and social interactions due to discomfort and visible symptoms. Clinically, she showed patches and plaques on her antecubital and popliteal fossae and buttocks, with excoriation and yellow crusts in some areas, covering about 8% of her body surface area (BSA) with moderate inflammation.

Diagnosis Considerations

Shahriari discussed the importance of keeping a broad differential and considering biopsies when standard treatments are ineffective, especially in skin of color where diseases may manifest differently. The panel noted that postinflammatory pigment changes, like hypopigmentation or hyperpigmentation, can significantly affect quality of life and should be addressed early in treatment planning.

Individualized Treatment

Previous therapies had not fully worked, with some causing adverse events, prompting consideration of newer treatments like ruxolitinib (Jakafi; Incyte). The patient could safely use the cream in other areas and see itch relief in as fast as 15 minutes. The panel discussed some factors noted in caution labels but ultimately decided to move forward, considering supporting research that found no adverse events in patients with similar experiences. Shahriari noted that the panel hoped the drug would soon be approved for patients as young as 2 years.

Accessibility

The panel addressed state regulations’ impact on how clinicians obtain this medication, often through specialty pharmacies and field access representatives. Panelists expressed concerns about label restrictions that prevent combining ruxolitinib with biologics like dupilumab despite patients’ need to manage flare-ups effectively. Shahriari said strategies to navigate these restrictions include appeals to insurance companies and peer-to-peer discussions. There is optimism that increased use will demonstrate ruxolitinib’s value in enhancing patient adherence and quality of life compared with traditional therapies, pending future developments in next-generation treatments like roflumilast (Zoryve; Arcutis).

Mona Shahriari, MD, FAAD, engages in discussing case questions with fellow clinicians.

Case 2: 36-Year-Old Man With History of AD

The second case involved a man aged 36 years with a history of AD since he was 2; it improved during adolescence and adulthood. Recently, his disease flared up on his trunk and arms after he had moved to a dusty apartment 6 months earlier, causing intense itching that was not responding well to topical corticosteroids. The patient has a history of depression and childhood asthma, and smokes.

Treatment Factors

Despite using corticosteroids, his AD remains uncontrolled, with symptoms recurring as soon as treatment stops. His quality of life is affected, as he cannot participate in activities due to skin irritation from sweating. Despite a good regimen and previous success, his disease is still not being adequately controlled. Shahriari and the panel emphasized the need to make treatment decisions with the patient, offering options such as topical, oral, or injectable therapies based on preferences and adherence capabilities.

Comorbidity Concerns

It is important to keep comorbidities in mind to avoid starting a treatment that overlooks other triggers contributing to flare-ups, which could hinder the patient’s response. Additionally, given his history of childhood asthma, the panel noted that therapies should address both his skin and respiratory issues if asthma is still a concern. The patient’s history of depression also warrants attention, and a collaborative approach involving psychologists or psychiatrists is crucial to addressing the broader impact of eczema on his mental health.

Result

Despite initial improvement with ruxolitinib, the patient struggled with regular use and still did not achieve adequate control, prompting consideration of oral or injectable therapies. He opted for dupilumab 300 mg every other week for convenience and saw significant improvement after 3 months, expressing regret for not starting earlier. Involving the patient was a key focus for the panel, ensuring he felt heard and comfortable discussing sensitive topics such as mental health impact and cultural considerations during treatment discussions.

Read part 3 featuring Robert Posnick, MD.