In this episode of Topical Conversations, Kristine Kucera, PA-C, and Aaron Farberg, MD, discuss the challenges of managing moderate atopic dermatitis (AD). This segment offers insights into how clinicians define moderate AD, set treatment goals, and decide when to move beyond topical therapies to systemic treatments. 

Defining moderate atopic dermatitis 

Dr Farberg highlights that defining the moderate AD patient can vary depending on the context. In clinical trials or insurance approvals, moderate to severe AD is often based on scoring systems like the EASI score. However, in practice, the definition relies on a more personal approach—talking to the patient and assessing the impact of the disease on their daily life. 

For clinicians, body surface area (BSA) is often used to classify AD severity, but Dr Farberg emphasizes that the location of eczema can sometimes be more telling than the extent of coverage. For example, AD affecting sensitive areas like the scalp or groin may have a significant impact on quality of life even if it doesn’t affect a large area of skin. He suggests that the key is understanding how AD affects the patient, which helps determine whether a patient should remain on topical treatments or transition to more systemic options. 

Treatment goals for moderate atopic dermatitis 

According to Kristine Kucera, setting clear treatment goals is critical, starting with patient education. Patients need to understand their condition and the rationale behind the treatment approach. Kucera advocates for shared decision-making to establish patient-specific treatment goals, ensuring both the clinician and patient are aligned on expectations. 

Patients may not always realize what is achievable with appropriate treatment. Kucera emphasizes that even if patients feel they are "doing okay," clinicians should probe deeper to assess if lingering flares or other symptoms remain. Better control of symptoms can significantly improve a patient’s quality of life, and patients often don’t realize how much improvement is possible. 

Dr Farberg highlights the importance of aiming for near-complete clearance. Studies in related conditions like psoriasis have shown that getting a patient from 75% to 90% or more clearance can lead to meaningful improvements in quality of life. This goal should be communicated clearly to patients, ensuring they understand that optimal control can be within reach. 

Skin care and basic advice for moderate AD patients 

Both Dr Farberg and Kucera stress the importance of providing patients with advice on basic skin care routines. Clinicians should not overlook recommending gentle skin care practices, including using gentle cleansers, moisturizing frequently, trimming nails to prevent scratching, and using a humidifier. 

These foundational steps can complement medical treatments, helping patients maintain better control over their symptoms. 

Transitioning to systemic treatments: when and why 

The decision to move from topical treatments to systemic therapies is pivotal in managing moderate AD. According to Dr Farberg, the conversation about systemic treatments should happen early, even during the first visit. Discussing options like JAK inhibitors and cytokine inhibitors, such as dupilumab (Dupixent), helps patients understand their choices upfront, reducing the likelihood of patients questioning why certain treatments weren’t offered sooner. 

For moderate AD, Dr Farberg emphasizes the importance of treating the disease as systemic from the outset. While topical therapies are useful, many patients require a systemic approach to achieve meaningful control. 

Dupilumab: a go-to treatment option 

When it comes to systemic therapies, dupilumab has emerged as a strong option in the treatment of moderate atopic dermatitis. Dr Farberg explains that dupilumab is well-tolerated, with a safety profile supported by years of use across various conditions. 

Patients are increasingly open to the idea of injections, particularly with the rising familiarity of injectables like GLP-1 inhibitors for other health conditions. Dupilumab’s every-two-week injection schedule, with the possibility of extending to once a month in certain cases, appeals to many patients who prefer fewer interventions compared to daily oral medications. 

Personalized care for moderate AD patients 

Both Kucera and Dr Farberg highlight the importance of personalized treatment approaches for moderate AD. Every patient is different, and clinicians need to be flexible in tailoring treatments to individual needs. With an array of available options, from topicals to systemics like dupilumab and JAK inhibitors, the goal is to find the right combination that maximizes each patient’s comfort and quality of life. 

By engaging in open discussions with patients, setting realistic treatment goals, and considering early transitions to systemic therapies, clinicians can help patients achieve better disease control and improve their daily lives.