In this episode of Topical Conversations, Heather Gates, PA-C, and Marc Serota, MD, explore the challenges and treatment strategies for patients with moderate atopic dermatitis (AD). They emphasize the importance of assessing patients accurately and highlight the evolving role of systemic therapies. 

Understanding moderate atopic dermatitis: assessing the patient 

Patients with moderate AD often present with fluctuating symptoms. They may appear well on the day of their visit but experience significant discomfort during flare-ups. According to Dr Serota, dermatologists must go beyond the snapshot of what they see in the office and dig deeper into the patient’s daily experience with the disease. Important factors to assess include: 

• Body surface area (BSA): Evaluate the extent of the skin involvement over time, not just at the visit. 
• Itch intensity: Gauge how severe the itch typically is, on a scale from 1 to 10. 
• Impact on daily life: Ask about the emotional and social effects, especially in pediatric patients who may experience itch during activities like sports or in school settings. 

These considerations often reveal that even if a patient seems to have mild symptoms in the office, their overall burden of disease is much more significant. 

Transitioning from topicals to systemic therapies 

Deciding when to transition from topical treatments to systemic options is crucial in AD management. As Heather Gates and Dr Serota explain, the availability of newer, safer systemic therapies has shifted the conversation. 

Both Gates and Serota agree that every patient with AD should have a topical treatment available, particularly nonsteroidal options. This remains a staple of treatment regardless of whether the patient is on systemic therapy. 

Historically, systemic treatments like methotrexate were avoided early in treatment plans, especially in pediatric cases. However, with the introduction of safer alternatives such as dupilumab, Dr Serota now initiates the conversation about systemic options early, even during the first visit for patients with moderate AD, noting that these patients deserve to be informed of all treatment options, and the decision on whether to start systemic therapy can be made collaboratively. 

Choosing a systemic therapy 

Selecting the right systemic therapy for moderate to severe AD depends on several factors, including the patient’s age, comorbid conditions, and the severity of their symptoms. Newer systemic therapies have provided safer alternatives to traditional treatments like methotrexate and cyclosporine, which were often associated with significant side effects. 

Dr Serota highlights the utility of dupilumab for patients with comorbid conditions, noting that with its indications for associated atopic conditions, it can address skin symptoms as well as target related conditions such as asthma, making it a holistic treatment option for patients with multiple atopic diseases. 

Communicating systemic treatment options to patients and parents 

When discussing the possibility of systemic treatments, setting realistic expectations is critical. Gates and Serota emphasize the importance of framing the conversation in a way that is clear, reassuring, and rooted in long-term management. 

Gates advises underselling the benefits and overdelivering. She stresses to parents that AD is a chronic disease, and the child will likely need long-term therapy. This helps prevent disappointment and encourages adherence. 

Dr Serota uses simple analogies to help explain systemic treatments. For example, he compares dupilumab to a radio signal blocker that specifically targets allergic cells, avoiding broad immunosuppression. He also compares the injection schedule to that of diabetes treatments, explaining that the infrequent administration (every two weeks or once a month) is manageable compared to daily insulin injections. 

Systemic therapy for moderate AD: a shift in treatment paradigms 

With advances in systemic therapies, the approach to treating moderate atopic dermatitis has shifted dramatically. Dermatologists are now empowered to initiate conversations about systemic treatments earlier in the disease course, offering patients the chance to live with less itch, better sleep, and improved quality of life. 

Even if patients choose not to proceed with systemic therapy, ensuring that they are aware of the benefits, risks, and availability of these treatments is essential for shared decision-making and better long-term outcomes.