In this episode of Topical Conversations, Dr Matthew Zirwas and Dr Peter Lio explore the complexities of managing moderate atopic dermatitis (AD), a condition that often poses unique challenges. The discussion highlights the importance of recognizing the distinct characteristics of moderate AD, understanding the common pitfalls in its management, and exploring effective strategies for improving patient outcomes. 

Identifying the moderate patient 

Dr Lio describes moderate AD as an especially intriguing category, occupying a middle ground that is neither as severe as the most extreme cases nor as mild as those easily managed with basic care. He explains that moderate AD can be deceptive, with clinical presentations that may appear mild but are often marked by significant symptoms like persistent itching and sleep disturbances. These patients may also show refractory responses to treatments typically effective for mild cases, indicating that they may, in fact, be dealing with moderate AD. 

A tendency to undertreat 

Dr Zirwas and Dr Lio discuss the tendency to undertreat patients with moderate AD due to the condition's refractory nature and the waxing-waning course of the disease. They highlight that moderate AD patients often visit the clinic during non-flare periods, leading to an underestimation of their condition. The doctors emphasize that patients may mistakenly believe that small adjustments to their regimen, such as switching topical steroids or skincare products, will suffice. However, this approach rarely brings about complete control of the disease, leaving patients vulnerable to future flares and ongoing discomfort. 

Patients’ struggle for control 

Dr Zirwas shares insights into the psychological burden faced by patients with moderate AD, particularly before the advent of effective treatments like dupilumab. He recalls patients who, despite being in a stable phase, would still experience significant anxiety about potential flares, especially during important life events like vacations or job interviews. The discussion reveals that the introduction of effective therapies has been transformative, offering patients a newfound sense of control over their disease. Dr Lio adds that before these treatments, patients often focused heavily on diet as a way to manage symptoms, seeking control through any available means. With the availability of more effective treatments, the emphasis on diet has decreased, as patients now have better options to manage their condition. 

Evaluating atopic dermatitis treatment results by efficacy 

Dr Zirwas outlines how he categorizes atopic dermatitis treatments based on their efficacy in clinical practice. He describes achieving a 90% improvement in the Eczema Area and Severity Index (EASI90) as an excellent response, with 75% improvement (EASI75) still being a very good outcome. He notes that patients at the EASI75 level often feel satisfied and resist changing therapies, whereas those at EASI50 might require continued use of steroids. Both doctors agree that dupilumab has been a game-changer, with most patients achieving significant improvements and few needing alternative therapies. 

Counseling reluctant patients on advanced therapies 

When it comes to counseling patients who are hesitant to start advanced therapies like dupilumab, Dr Zirwas and Dr Lio emphasize the importance of clear communication and reassurance. Dr Zirwas shares his strategy of explaining to patients that IL-13 blockers like dupilumab can lead to a substantial decrease in skin infections, improving overall immune function rather than suppressing it. He finds that this explanation often encourages hesitant patients to try the treatment. Dr Lio concurs and adds that he uses visual aids, such as a laminated slide showing reduced infection rates, to reinforce the benefits of treatment. He also highlights recent studies showing that dupilumab can normalize the skin microbiome, which he believes is a crucial aspect of managing AD. To further ease patients' concerns, Dr Lio promises that the treatment is not a lifelong commitment and that many patients can eventually stop the therapy and maintain their improvements. This reassurance helps patients feel more comfortable and open to starting the treatment. 

Addressing the full spectrum of moderate AD 

In their concluding remarks, Dr Zirwas and Dr Lio stress the importance of not settling for minor tweaks in treatment when managing moderate AD. They emphasize that dermatologists should closely monitor the impact of the disease on patients' sleep and overall quality of life, as these are critical indicators of the need for more aggressive treatment. They also advocate for structured, open conversations with patients about their symptoms, particularly regarding sleep and itchiness. With the availability of effective treatments, it is essential for dermatologists to engage in shared decision-making with their patients to achieve the best possible outcomes.