Factors that Impact Therapy Decisions for Atopic Dermatitis (AD)

Factors that Impact Therapy Decisions for Atopic Dermatitis (AD)

Disease Factors

• Severity: Mild (limited areas, minimal impact), moderate (larger areas, frequent flares), severe (widespread, persistent)

• Distribution pattern: Facial/sensitive areas require less potent agents; thick/lichenified areas may need higher potency

• Acute vs. chronic: Weeping/exudative lesions benefit from drying agents; chronic lichenification requires stronger anti-inflammatory approaches

• Flare frequency: Recurrent flares may warrant maintenance therapy or trigger identification

Patient-Specific Considerations

• Age: Pediatric patients have increased percutaneous absorption and BSA-to-weight ratio

• Comorbidities: Immunodeficiency, diabetes, hypertension may impact systemic therapy selection

• Occupational factors: Hand involvement in healthcare/food workers requires special consideration

• Pregnancy/lactation status: Category B/C agents preferred; benefit-risk assessment required

• Therapy adherence history: Simplified regimens for those with adherence challenges

Practical Considerations

• Treatment burden: Complex regimens less likely to achieve adherence

• Vehicle preference: Ointments for dry skin; creams for weeping lesions; lotions for hairy areas

• Cost and insurance coverage: Newer agents often have significant cost barriers

• Access to care: Follow-up capabilities influence therapy selection

• Previous treatment response: Prior failures guide escalation decisions

Psychosocial Factors

• Quality of life impact: Significant impairment warrants more aggressive approaches

• Sleep disruption: Severe nocturnal pruritus may require systemic agents

• Steroid phobia: Steroid-sparing agents may be preferable despite potentially lower efficacy

• Body image concerns: Visible areas may warrant prioritization of cosmetically acceptable vehicles

• School/work performance: Significant disruption justifies earlier systemic intervention

Special Populations

• Infants: Higher BSA:weight ratio increases systemic absorption risk

• Adolescents: Adherence challenges and body image concerns influence selection

• Elderly: Skin thinning and comorbidities affect risk-benefit assessment

• Ethnic skin variations: Increased post-inflammatory hyperpigmentation risk in darker skin tones

Emerging Considerations

• Biomarkers: Serum IgE, thymus and activation-regulated chemokine (TARC) levels may guide therapy

• Genetic factors: Filaggrin mutations may predict more severe disease course

• Microbiome analysis: S. aureus colonization may warrant antimicrobial approaches

• Endotyping: Th2-high vs. other inflammatory patterns may guide targeted therapies

Shared Decision-Making Elements

• Patient treatment goals: Prioritizing itch control vs. appearance vs. prevention

• Risk tolerance: Acceptance of potential side effects vs. preference for conservative approaches

• Personal values: Natural vs. conventional medicine preferences

• Lifestyle factors: Time available for treatment application and follow-up