Exploring the Atopic Dermatitis Treatment Paradigm and Challenging Cases

In a recent Dermatology Times Case-Based Peer Perspective custom video series, “Atopic Dermatitis in Practice: Case Studies From Diagnosis to Treatment,” Andrea Rosik, MS, PA-C, provided insights into managing atopic dermatitis (AD). Rosik, a dermatology physician assistant practicing at Hamzavi Dermatology in Shelby Township, Michigan, assessed 2 patient case studies to offer clinical advice for challenging AD cases.

Case 1: Psoriasis in a Woman With a Complex History

Rosik presented the case of a White woman aged 70 years with a history of hypertension, acid reflux, hypothyroidism, and psoriasis. The patient reported a diffuse rash following a COVID-19 infection, with symptoms affecting her scalp, face, extremities, and torso.

“She was complaining of some itching, flaking, scaling, and redness,” Rosik said. “She had a worsening of her skin condition, especially after an illness such as COVID-19.”

However, the roundtable attendees considered differential diagnoses, including an eczematous process, contact dermatitis, or a psoriasiform drug eruption. A biopsy was performed, revealing psoriasiform spongiotic dermatitis. This result prompted the group to discuss various interpretations of the biopsy findings, concluding that psoriasis, drug eruptions, or contact dermatitis could all be plausible.

The patient’s initial treatments included salicylic acid shampoo and topical steroids, which provided little relief. In frustration, she returned to the clinic, where Rosik and her team prescribed vitamin D analogues, topical calcineurin inhibitors, and topical steroids. Given her persistent symptoms, she was eventually started on an IL-23 inhibitor.

“Upon discussion with the group, the group had [concluded] that many of us providers would suggest alternativ treatment options for this patient. In-office samples were helpful, in this case, to start patients on medication after all the appropriate testing is performed and to get the patient on a drug while insurance approval is taking place,” Rosik said.

The patient saw some improvement but continued to experience a persistent rash. Rosik noted the patient’s frustration and ongoing symptoms, prompting further discussions about treatment approaches.

“When she was back in Michigan, she said her rash wasn’t completely resolved. She was still itching. She still had that scaling on her scalp, face, and extremities, and she was not completely clear,” Rosik said. “We had reviewed her biopsy results...and therefore, we had started her on dupilumab, which resulted in significant skin clearance.”

Despite the improvement, the patient returned with a small, itchy patch on her arm, and Rosik’s team provided samples of ruxolitinib cream, which helped address her flare-ups. The team also considered her complaint of joint pain and temporarily paused her dupilumab therapy to assess whether it was contributing to the symptoms.

Case 2: Chronic Atopic Dermatitis in a Man

The second case focused on a White man aged 37 years with a long history of asthma and AD. The patient reported a recurring rash that worsened over time. He had tried various treatments, including topical steroids, tacrolimus, and phototherapy, but struggled with managing his condition due to his work schedule.

The patient had been on dupilumab since 2018, which improved his quality of life, but he continued to experience flare-ups, particularly when sweating. At his follow-up visit, the patient expressed satisfaction with the improvement in his skin after using ruxolitinib cream. This outcome led to a broader group discussion about the benefits of nonsteroidal alternatives for patients who struggle with itching and topical steroid overuse.

“It was discussed that sweating also fits into atopic dermatitis,” Rosik noted. “At the patient’s follow-up visit, he was stating that his skin was much improved, and he really liked the ruxolitinib cream, and it significantly cleared up his skin and especially helped with any itching.”

The roundtable discussion concluded that ruxolitinib cream would be a beneficial alternative for this patient, particularly in addressing flare-ups. Rosik emphasized that nonsteroidal treatments like ruxolitinib are effective, well tolerated, and valuable for patients with sensitive skin.