Defining Treatment Options for Managing Chronic Atopic Dermatitis: Part 3

During a recent Dermatology Times Case-Based Peer Perspective custom video series, “In the Clinic: Exploring Atopic Dermatitis Through Real Patient Cases,” Jayme Heim, MSN, FNP-BC, provided insights into managing atopic dermatitis (AD).

Heim, a nurse practitioner at West Michigan Dermatology in Grandville, Michigan, detailed 2 patient case studies discussed in a recent roundtable of western Michigan–based dermatology advanced practice providers (APPs). Heim said each APP’s years of experience varied, from less than 5 to more than 20, making for a well-rounded, vibrant discussion.

Case 1: A 20-Year-Old Woman With Short History of Hand Rash

The first case discussed was that of a 20-year-old college student with a 6-month history of hand rash. According to Heim, the woman recently began an internship as a laboratory technician and believes the various chemicals could be causing the rashes.

To start the discussion, the cohort said this is a patient type often referred to their respective dermatologic practices. Heim noted several important factors: who referred the patient, previous therapies such as prednisone, and whether any chemicals she noticed worsened the rash.

Heim says the patient was initially diagnosed with contact dermatitis. Upon negative results from a patch test, she was started on topical corticosteroid cream with instructions to apply it with gloves. This gave her partial improvement in symptoms, but she still saw frequent flare-ups and noted that the constant use of gloves was exacerbating the condition.

The diagnosis was then revised to AD, and the patient was switched to treatment with pimecrolimus cream 1% twice daily plus topical corticosteroid with severe flare-ups. With this therapy, Heim said the patient reported initial improvement, but it was not sustained, leading her to voice concerns about long-term treatment options.

Evaluating for a Chronic Condition

When assessing long-term therapies, many in the cohort felt that dupilumab would be a good option for the patient. Heim noted that if the patient were switched to another topical, the follow-up would have to be much sooner, whereas a systemic would have a longer onset period. She emphasized communicating and following up with patients to ensure they see the desired results. In the end, the group decided the next best step for the patient would be to start her on dupilumab for a chronic condition.

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

The second case was that of a 36-year-old software engineer with a history of AD since childhood. He reported the disease worsening over the past year, with a constant itch, sleep disturbance, and difficulty focusing at work. He has a history of asthma that he controlled using inhaled corticosteroids, a body surface area of 8%, and an investigator’s global assessment of 3. The patient says he intermittently uses over-the-counter hydrocortisone cream, which gives him temporary relief.

The group felt that this was not a reliable therapy for the patient and that he had never been properly educated on his disease process. They felt that educating the patient on his disease state, as well as the atopic march, would help the patient and clinician to make an informed, shared decision.

Deciding Between Diverse Therapy Options

The group discussed the option of topical steroids but voiced concerns regarding regulating use and possible atrophy. According to Heim, the group had difficulty reaching a consensus on this case. However, they all agreed that, in extreme cases, the use of oral steroids and intramuscular injections is best while starting a systemic therapy.

As the cohort considered how best to understand this patient’s individual needs. One note they made involved the role of insurance in the treatment process and the need to make therapies attainable to ensure adherence. “If that patient came into our office, we probably would discuss with them day 1 going on a systemic agent that is FDA approved for atopic dermatitis,” Heim said. “However, because of insurance, we have to work with all the DMARC statuses.”

Heim said that they felt they must do what was in the patient’s best interest: start him on a topical steroid or topical calcineurin inhibitors on top of a DMARC. With this treatment plan, the patient reported minimal improvement at follow-up, and the decision was made to try a new mechanism of action. The patient was then prescribed upadacitinib to be taken daily, plus topical therapy during flare-ups.

Heim noted the major factors that influenced the decision-making in this case: the chronicity of the disease, the patient’s atopic triad, the impact on quality of life, and the fact that the patient was presenting with moderate disease.

After 2 weeks, Heim said the patient began to see a positive response. However, the group agreed that this would need to be a continuous therapy for the patient. They classified his disease as chronic and noted that tapering or stopping medication would only result in another flare-up. With notable adherence issues, the patient was finally prescribed ruxolitinib. At his 3-month follow-up, Heim said the patient reported his AD noticeably clearing after a few weeks and completely clearing after 2 months of the new therapy.