Clinical Insights Into Challenging Atopic Dermatitis Cases: Part 3

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 2 featuring Mona Shahriari, MD

Merrimack, New Hampshire

Robert Posnick, MD, a board-certified medical dermatologist with Nashua Dermatology Associates in Nashua, New Hampshire, hosted a Case-Based Roundtable discussion in Merrimack.

Case 1: Adolescent Male With Hyperpigmentation Issues

The first case involved a male aged 13 years with Fitzpatrick skin type IV, a skin of color patient with eczema since childhood. His primary complaint was hyperpigmentation in typical areas: the antecubital fossae and behind the knees, neck, and face. His primary care provider had prescribed triamcinolone cream, a common topical steroid, but the patient and his mother were concerned about persistent hyperpigmentation. Additionally, he had white patches on his face, initially misdiagnosed as a fungal infection but correctly identified as pityriasis alba, another manifestation of AD.

Treatment Considerations

To avoid chronic use of topical steroids, particularly on the face, Posnick decided to treat the patient with a topical calcineurin inhibitor. The safety issues of topical steroids vs topical calcineurin inhibitors were discussed, highlighting the risks of hypopigmentation and skin thinning from overuse of topical steroids. Tacrolimus ointment 0.1% was chosen for his treatment. The rare but potential risk of malignancies associated with topical calcineurin inhibitors was also addressed, although studies show this is very unlikely.

Plan Adjustments

The patient initially experienced stinging and burning from the topical calcineurin inhibitor and the PDE4 inhibitor crisaborole, leading him to revert to using topical steroids on his face. Posnick then recommended ruxolitinib cream as the next-best choice. The safety profiles of topical and oral JAK inhibitors were compared, emphasizing that the lymphoma and cancer risks associated with oral JAK inhibitors are not as pronounced with topical applications.

Outcome

Posnick reassured the patient’s mother about the low risk of malignancies and decided not to routinely biopsy AD, as it is typically diagnosed clinically. The patient agreed to use ruxolitinib cream, clearing both the hyperpigmented and hypopigmented areas on his skin.

Robert Posnick, MD, leads a discussion surrounded by fellow New Hampshire dermatology professionals.

Case 2: Adult Female With Severe AD and Alopecia Areata

The second case involved a fair-skinned woman aged 55 years with a long history of AD, asthma, and severe alopecia areata, eventually leading to alopecia totalis. Despite her overall good health, she was stressed from a divorce and had a history of recurrent cold sores. Her eczema covered 15% of her BSA, making her a candidate for treatment with topical ruxolitinib cream, approved for up to 20% BSA for AD.

Treatment Considerations

She had tried numerous treatments, including topical steroids, calcineurin inhibitors, and PDE4 inhibitors, with limited success. Posnick decided to start her on topical ruxolitinib cream and dupilumab for her severe AD. For immediate relief, high-potency topical steroids were prescribed for use until the other medications arrived. Due to her history of cold sores, a prescription for episodic antiviral treatment was provided rather than suppressive therapy.

Relationship Between AD and Alopecia Areata

The patient responded well to ruxolitinib cream and dupilumab, experiencing significant improvement in her eczema. However, there was no change in her alopecia areata. Posnick discussed the relationship between AD and alopecia areata, noting that although AD is more common, a significant percentage of patients with alopecia areata also have AD.

Consideration of Oral JAK Inhibitors

The potential use of oral JAK inhibitors for patients with both conditions was also discussed, emphasizing the need to consider safety and efficacy when choosing systemic treatments. Posnick concluded that oral JAK inhibitors should be a second-line systemic treatment for AD due to their safety profile.

Read the full supplement here.