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Professor, Department of Pediatrics
Chief, Division of Dermatology
Seattle Children's Hospital
University of Washington School of Medicine
Robert Sidbury, MD, MPH: consultant/advisor/speaker: Beiersdorf, Leo, Lilly.
This commentary summarizes key takeaways on managing therapy of patients with moderate to severe atopic dermatitis presented during the 2022 Dermatology Intensive titled Taking Patient Care to the Next Level: Addressing the Clinical Challenges Impacting the Management of Dermatologic Conditions.
Advances in AD Therapy Options
It is a pretty amazing time right now in atopic dermatitis (AD) therapeutics. I finished my fellowship in the year 2000 and for 17 years of my practice, there were basically no new therapeutic molecules until 2017—there was nothing. Nothing new. Then dupilumab came out, and gradually that has gained FDA approval at younger and younger age groups, now as young as 6 months of age, which is extraordinary in and of itself.
On top of that, in the last year there have been several other novel agents approved. These include 3 Janus kinase (JAK) inhibitors, topical ruxolitinib, and oral upadacitinib, both approved for kids 12 years and older. Additionally, there is abrocitinib, an oral JAK inhibitor for adults. We also have a new biologic agent, tralokinumab, which was recently approved as well. With the expanded approval of the topical nonsteroidal agent crisaborole down to 3 months of age, there are an amazing number of new therapeutic options for patients with eczema across the full age spectrum.
Racial and Ethnic Disparities in AD Care
We have also learned a lot in the last few years regarding different presentations of AD in persons of color. First, AD is more common than previously appreciated in Black and other racial and ethnic minorities. Additionally, the presentation of AD is not identical across various skin types or colors within these populations.
Erythema, or redness, presents differently based on Fitzpatrick skin types. It is much more apparent in those with lighter skin types (eg, Fitzpatrick type 1) as opposed to darker skin types, (eg, Fitzpatrick type 6). The depth of pigmentation can obscure erythema, which can lead to underappreciation of skin inflammation. This can be a huge problem. Misdiagnosis can lead to misattribution of certain clinical features and therapeutic misadventures. Skin that doesn't look particularly red, even if the diagnosis of AD is known, gives the false impression of less inflammation because erythema is thought to be the most obvious sign of AD.
AD can also present as more follicular in patients with dark skin, appearing more like “goosebumps.” This can be on the trunk or in focal plaques and may not be recognized as inflamed skin. Again, this doesn’t align with the traditional understanding of the AD presentation which includes more ill-defined plaques on the flexures of the elbows or backs of knees.
Healthcare professionals (HCPs) who train in undiversified areas are not likely to see a broad range of skin types or disease manifestations. Then, of course, they are not necessarily going to appreciate these differences when they get out into practice. This speaks to a bigger problem, which is the need for more diversity in the HCP population; one that mirrors our population in the United States. With our goal of having equitable care, this should be a focus to achieve that.
Barriers to Optimal Pediatric to Adult Care Transitions in AD
I've worked at children's hospitals all my life and can attest that, just like parents, pediatric HCPs coddle our patients to a certain extent. For example, if they miss an appointment, we'll call and say, "Hey, where were you? Why couldn’t you make your appointment? What’s going on? Let’s make sure everything is okay”. This parental approach inevitably wanes as patients get older and are transitioning into adulthood; the next thing you know, patients are no longer coming to appointments on their own. They're finding their own legs as young adults, and sometimes aren’t as good about keeping appointments or managing their disease.
When you have a system that they’re used to, it is easier for HCPs to remind patients and help fill in the gaps when they don't take care of things themselves; in systems without those population-specific safety nets, patients may get lost to follow-up. So, it is important for HCPs on the pediatric end to prepare their patients and help usher them into the world of adult healthcare. And when HCPs on the adult care side start receiving young adults who have been in a different care system, they should be cognizant to preempt and proactively address gaps in care during times of transitions.
What are your thoughts and questions on managing patients with moderate to severe atopic dermatitis? Please join the conversation by posting a comment in the discussion section below.