Addressing Current Topical Management of Atopic Dermatitis in Primary Care

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Medical Discussion on Atopic Dermatitis Management

Impact on Quality of Life

• Survey of 600 adults with atopic dermatitis showed quality of life impacts across all severity levels:
  • 11% of patients with mild symptoms reported moderate/large impact
  • 37% of patients with moderate symptoms reported moderate/large impact
  • 68% of patients with severe symptoms reported moderate/large impact
• Even small, affected body surface area (BSA) can significantly impact quality of life:
  • Hand eczema (2% BSA) affects daily activities in chefs, health care workers, etc
  • Facial eczema impacts mental health and self-esteem despite small BSA
  • Plantar foot eczema interferes with footwear and exercise

Treatment Decision Factors

• Poll results on most important factors when selecting treatments:
  • Effectiveness of treatment: 80%
  • Patient preference: high consideration
  • Risk of adverse effects: 60%
  • Treatment cost: 90% (highest priority)
• Insurance coverage and prior authorization are significant considerations
• Administrative burden in getting therapeutics approved necessitates proper documentation with symptom scales
• Importance of shared decision-making with patients after providing balanced information

Topical Treatment Guidelines (2018)

• Topical corticosteroids:
  • Recommended for intermittent use of medium potency formulations
  • Should be used for short bursts (1-2 weeks) followed by breaks to avoid adverse effects
• Topical calcineurin inhibitors (eg, tacrolimus):
  • Strong recommendation for mild-moderate disease
  • Can be used more regularly with better local safety but modest efficacy compared with steroids
• Newer agents:
  • Phosphodiesterase-4 inhibitors (crisaborole ointment)
  • Janus kinase inhibitors (topical ruxolitinib)
  • Aryl hydrocarbon receptor agonist (tapinarof cream)

Current Clinical Practice Patterns

• Poll results showed topical corticosteroids overwhelmingly remain first-line therapy
• For patients with inadequate response to initial treatment:
  • Most physicians choose another topical corticosteroid
  • Some utilize phosphodiesterase-4 inhibitors
  • Referral to dermatology specialist is also common

Key Clinical Considerations

• Importance of counseling patients on proper corticosteroid use (intermittent application)
• Need to discuss potential adverse effects: striae, atrophy, hypopigmentation
• Even normal-appearing skin can have underlying inflammation
• Assessment of itch is crucial for comprehensive evaluation