Physician Spotlight

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How have understandings evolved on eczema since you have been in practice?

The changes have been fundamental and rapid, according to Dr. Sidbury. “When I trained, filaggrin was associated with ichthyosis vulgaris but no one had linked it to AD yet. Likewise the idea of eczema as an ‘inside out’ disorder (primarily immune dysfunction) as opposed to ‘outside-in’ (primarily a barrier defect) was the predominant viewpoint where now that has flipped,” he notes. “This more granular understanding is now leading to a cascade of targeted therapies the likes of which we have never seen before. The National Eczema Association calls this ‘the decade of eczema’ for good reason!”

When it comes to treatment, what factors do you consider when you are selecting a therapeutic regimen for a patient?

Among the many elements to consider is age, says Dr. Sidbury. “The younger the child, the more I will try to use less potent agents.” Another consideration is distribution. “Palms/soles will likely require and tolerate a much stronger product that face, for example.” Other factors to think about include prior treatments, disease severity and impact on quality of life, compliance with good skin care practices (e.g. use of moisturizers), and vehicle preference, according to Dr. Sidbury. “While I may like ointments better, my teenaged patient with facial dermatitis may not and the most effective product in the world isn’t when sitting untouched on the shelf.” Season and climate conditions can affect vehicle, as well. “Thick ointments may be too occlusive and uncomfortable in hot, humid weather,” he says. Finally, it is always important to consider what Dr. Sidbury calls therapeutic context. “Are the parents/patient afraid of the products you are considering (e.g. topical corticosteroids, black box warnings etc)? Can they overcome that fear with education or is that unlikely? Those are some of the features that often factor into this decision.”

What would you like to see happen in the next several years regarding how eczema is approached and managed?

“I would like to see less misunderstanding across the board in terms of what eczema is and how it should be managed. When I see patients and parents now they are often so flummoxed by the divergent recommendations they have received from various sources, including primary care doctors, dermatologists, allergists, friends, and Dr. Google, to name a few,” Dr. Sidbury observes. “I am hopeful that with the help of advocacy groups like the National Eczema Association, trends towards standardized care and clinical work, campaigns to minimize inefficient and ineffective use of medical resources (e.g. Choosing Wisely campaign), and the advent of newer and more effective therapies, that eczema will be less impactful on a patient born in 2020 than one born in 2000.” n

DR. SIDBURY IN-FOCUS

Dr. Sidbury is an Associate Professor of Dermatology at the University of Washington Medical Center and Division Chief of Dermatology at Seattle Children’s Hospital. The recipient of “Top Doctor” designation by Seattle Magazine for three years running. Dr. Sidbury is also the co-chair of the National Eczema Association.