Transcript
Dr. Walter Liszewski (00:16):
Hello, everyone. My name is Walter Liszewski. I am a dermatologist at Northwestern University in Chicago, and thank you for joining us today on Deep Dive. Today is where we will be discussing atopic dermatitis, and I'm excited to have one of my colleagues, Dr. Adelaide Hebert, who is a professor of dermatology and pediatric dermatology at UTHealth McGovern School of Medicine at Houston. Dr. Hebert, thank you so much for joining me.
Dr. Adelaide Hebert (00:44):
Thank you, Walter. It's a pleasure to be with you, and I'm so excited that we get to discuss some of the new medications available to treat atopic dermatitis.
Dr. Walter Liszewski (00:53):
Yeah, atopic dermatitis is really interesting because it's a common disease. It's something that we all see as dermatologists, but knowing which medications to use can be challenging, especially for pediatric patients. It can be really challenging trying to find things that are safe yet effective, that children are able to tolerate, and parents feel, frankly, comfortable using. So when it comes to treating atopic dermatitis, whether that be in younger children or adolescents or teenagers or even adults, what are you looking for in terms of disease control?
Dr. Adelaide Hebert (01:28):
What I want to see in terms of disease control is what is it that the patient not only can get on their insurance plan, but also what are they really going to use? We try to make the regimen as simple and straightforward as possible. We know when parents have one or two kids that have atopic dermatitis, it's a real time-consuming operative to take care of their skin.
(01:50):
So again, simplification is really often the cornerstone, but disease severity can also impact what I choose for my patients suffering with atopic dermatitis. We're very fortunate to have three topical medicines that are available, that are steroid-free, that are on many insurance plans readily available, and that seem to have wide acceptance by both patients and parents alike.
Dr. Walter Liszewski (02:13):
Yeah, and I agree with that. It's very challenging, especially for parents because they're having to take care of themselves and multiple children, and it can be really challenging to use these really strict forms of atopic derm management. I remember when I was a resident that sometimes we would have to soak and smear, and then we would have a cream for the face and for the body because historically we didn't have a lot of great options.
(02:38):
Fortunately, we do have a variety of newer non-steroidal topicals like tapinarof, which have in many ways changed my practice. So instead of having to tell someone, "You're going to use tacrolimus on the face, you'll use mometasone or triamcinolone on the body," you can use a medication like tapinarof, which is highly effective at controlling inflammation and repairing the skin barrier, and it can safely be used from head to toe. And it just makes things simpler.
(03:06):
It's one tube, you apply it, and parents are ready to go. It's interesting too, in my adult population, it can still be very time-consuming to have to juggle many different topicals. And one of the things that I've noticed over the years is really a lot of fear around using prescription steroids long-term. Not without evidence. We do know that topical steroids can be effective.
(03:32):
And in many situations, they really are our go-to, especially first line. But that's also where when we think about atopic dermatitis, because it is a chronic medical condition, having the ability to select products that are more sustainable, safer to use long-term helps us create a treatment plan that's ultimately going to get patients under good control while minimizing the potential for side effects. What are your thoughts on that?
Dr. Adelaide Hebert (04:00):
Well, I have to agree. I get some pushback also with regard to use of steroids, but often I need to get the patient under better control very quickly. And because some of the newer medicines have to go through a specialty pharmacy, there may be a delay, even a day or two, of getting a therapy that will be helpful to the patient. I see many patients that are actually undertreated with regard to their atopic dermatitis. They're on one or two and a half percent hydrocortisone, which isn't going to touch their disease.
(04:29):
So I might give a mid-potency steroid for daily use, at least until we can get the new medication, which is steroid-free. So I face the same challenges, but one of the rewarding components of the newer medicines is that virtually all of the new medicines go down to age three. And that's a population I see on a regular basis as a pediatric dermatologist. Parents are reassured when they know that the FDA has given the approval for this drug, even in such a young age group with a defective barrier that needs proper treatment.
Dr. Walter Liszewski (05:03):
Well, you just said something that was really interesting there, and this resonates for me as someone who predominantly sees adults. Now, I patch test. I patch test from the age of six months to a hundred, everyone in between. But most of my severe atopic, moderate to severe atopic dermatitis patients are adults. And having that approval from the FDA down to age two can be huge because it really emphasizes safety. And for patients who are dealing with atopic dermatitis, it's uncomfortable.
(05:34):
They don't know how long it's going to last for. They're worried about long-term use of medication. It can be very reassuring knowing that even in young children, there is evidence that these medications can be used safely. It makes people more comfortable. Now, within the non-steroidal space, I want to talk a little bit about tapinarof. And tapinarof is really first in class unique mechanism of action. So it works by being an agonist of the aryl hydrocarbon receptor. How do you use tapinarof? What has been your experience with it in patients with atopic dermatitis?
Dr. Adelaide Hebert (06:10):
Well, I have to say that having conducted the clinical trials, I was really impressed with the efficacy as well as the safety of tapinarof, even in the very youngest patients. During the study, we actually enrolled one patient in the maximal use study who had about 90% body surface area. There was no evidence of absorption that was of concern, even with that large application to that particular patient's body surface area affected with atopic dermatitis.
(06:36):
So safety is one thing. In addition, we know from previous evidence that even if a small child with tapinarof, let's say on their hand or fingers, they put their hand in their mouth, it doesn't pose a danger to the child because we don't have the receptors internally that would allow absorption of this particular drug. It's not that I'm advocating for oral use. I'm certainly not. But let's face it, when we treat our little patients-
Dr. Walter Liszewski (07:01):
It happens.
Dr. Adelaide Hebert (07:02):
... they don't have self-control and parents will express concern about using a medication on the hands or any other body surface where the child might inadvertently put that body surface into the mouth, which is a common occurrence. So again, another reassuring factor occurs here when we can talk about that. One of the other arenas where I think it's really important in educating parents about the use of tapinarof is to keep the tube cap up because there is a wide opening on the cap surface.
(07:34):
And if they happen to invert the tube, too much medicine will come out, which can result in overapplication because patients and parents don't want to waste the medicine. But overapplication can result in irritation. It's also completely unnecessary to use more medicine. A thin film actually works very effectively to control atopic dermatitis. In fact, we haven't discussed the remittive properties of tapinarof, but I think it's one of the most exciting factors that leads us to select this drug, particularly for a chronically lapsing disease such as atopic dermatitis.
Dr. Walter Liszewski (08:07):
Absolutely. And there's a couple of things there to unpack that I think were really important. So first is just the mechanism of action of how tapinarof works. We don't fully understand it. The mechanism behind how it works is really continuing to be elucidated, but the overarching principle is is that it helps to decrease pro-inflammatory cytokines that can damage the skin while also helping to restore the skin barrier and also increasing natural proteins that create the skin barrier and help create moisture retention within the skin.
(08:43):
And that's why we're able to see improvements in itch, improvements in inflammation, but also restoration of the skin barrier itself. The other thing that you mentioned is the sort of remittive potential of tapinarof. Now, in the clinical trials, both for psoriasis and atopic dermatitis, it is approved in children and adults for atopic dermatitis. And for psoriasis, it's approved for adults. One of the cool things that was done in the clinical trials was a withdrawal period.
(09:14):
And we know on average that when patients are able to clear with tapinarof, it's somewhere around 70 to 90 days before their disease starts to return, which is incredible. Because I don't know about you, but with me, with my patient population, particularly in adults, whenever I mention treatments, the first question out of everyone's mouth is, how long do I have to use this for? No one wants to be on medications long-term.
(09:41):
So the fact that tapinarof can be used, is well tolerated, is able to get even fairly severe disease under control, and then many patients are able to go into this remittive phase where they don't have to use the cream is a huge selling point for patients. Patients love that. And I remember one of my patients, so she was a woman in her late 20s. She was referred to me for patch testing. She had pretty severe head and neck eczema, as well as some involvement of her shoulders and hands.
(10:15):
We did patch testing. We didn't find anything relevant. So I knew on the final day of patch testing this was not allergic contact dermatitis. This was atopic dermatitis. And she just started crying. I remember this. And she was just so upset. She was frustrated. "I've been dealing with this rash. I have so many creams at home. I'm sick and tired of this. I don't want to keep doing this."
(10:40):
And that's when I offered her tapinarof. And the way I framed it to her was, "I'm sorry you're going through this, but there's something different we can do." Because up to this point, she'd only used tacrolimus or topical steroids. We could use something that's not a steroid. You can use it on your face and your shoulders and your hands. So number one, we can simplify your treatment routine. You don't have to have multiple tubes at home.
(11:05):
And then number two, once we can get you under control, there's a good chance you'll be able to stop it for a period of time. And if the eczema returns, we just repeat it. And she was very much open to it. And so she started on tapinarof. And sure enough, she eventually cleared and she went into a really nice remittance period of about four months. And when it started to come back, not as bad, she just reapplied it. And I've been following her now for about almost a year.
(11:35):
And every time I see her, she really gushes about how much that tapinarof really changed her life because it allowed her to simplify her routine and it gave her hope that she wasn't going to constantly be battling her atopic dermatitis, that she had a sort of silver bullet to really get it under control. And as a physician, that's the best feeling ever when you get to really help patients and they have these massive breakthroughs.
Dr. Adelaide Hebert (12:01):
Yeah, I'd like to share a similar story. I had a young man, a child that I enrolled in the clinical trial, and the main question that I get when I walk in the room, just like you, is not only when can I get off the medicine, but do I get a shot? And of course, that's a big parameter within the realm of pediatric dermatology. And this was a child that I enrolled in the clinical trial when I offered a topical medicine used once a day versus a biologic, which this patient could have readily been treated by a biologic.
(12:31):
There was no question that this child was willing to participate and the parent as well in the clinical trial. And the truth is carried forward to the mainstream patients that we see every day as the clinical trial, of course, is long since completed. But I think I've had an excellent reception when I talk about using a cream. And again, once daily application, a single agent for all body parts, including head and neck, as you alluded to. I just think simplifying this regimen, not offering a shot, offering a steroid-free product that is approved down to two years of age, this is really great for us as physicians.
(13:05):
It simplifies what we need to educate our patients about. We don't need much convincing when we have so many positives to share about this new medicine, which has really been a game changer in the realm of topical therapy for atopic dermatitis. And remember too, tapinarof is actually the only topical approved for mild, moderate, and severe atopic dermatitis. And we know from the clinical trials, all arenas of atopic dermatitis can be successfully managed with using tapinarof once daily.
Dr. Walter Liszewski (13:36):
Absolutely. And I think that's really where it has potential. And you alluded to this, definitely for mild and moderates, it's very clear where non-steroidal topicals like tapinarof can be helpful, but also in the severe stage, not every patient wants to do a biologic. There may be reasons why there are contraindications to it. And being aware that you can use a medication like tapinarof is helpful. The other thing too is atopic dermatitis is fluid. Sometimes you're going to have mild disease, sometimes you may have more severe.
(14:07):
Really having something that has that flexibility for you to tackle it at its best and its worst is very, very helpful. Now, I have another question. We know with atopic dermatitis, it has a huge impact on children as well as everyone in the family in terms of sleep, in terms of development, in terms of focusing at school. In what ways have you noticed that tapinarof can help patients who are having a lot of social and health-related issues due to their atopic dermatitis?
Dr. Adelaide Hebert (14:39):
Well, certainly this is something I deal with every day because we're treating not just the skin, we're treating the whole patient and often the family as well. And I have seen indeed, and we have from the clinical trials, evidence of improved quality of life. There's certainly a lot less itching. There's much better disease control. There's repair of the barrier. You mentioned that getting these medications such as tapinarof from a specialty pharmacy, that simplifies the whole regimen and I feel improves compliance.
(15:06):
I've had a couple of patients also where I've seen when their disease came under control, their growth immediately picked up. While I don't have any data to cite specifically, again, it's another quality of life parameter that we see that has been enhanced by the use of this once-daily steroid-free tapinarof to help control atopic dermatitis.
Dr. Walter Liszewski (15:28):
That's fascinating, but I really think it just speaks to the inflammation that can occur in diseases like atopic dermatitis. They don't just impact the skin, they can impact multiple facets of an individual's health, but also their mental health as well.
Dr. Adelaide Hebert (15:43):
I agree.
Dr. Walter Liszewski (15:44):
And final question, anything else you would like to share with our audience about non-steroidals and tapinarof and how they can integrate them into their practice?
Dr. Adelaide Hebert (15:53):
Well, I have one specific recommendation. Certainly if your patient participates in sports or exercise and they're getting ready to go let's say out in the Houston heat or any other area where it might be warm, that's not the ideal time to be applying their tapinarof. It's probably better if they put it on at night when it's a little bit cooler and they're not going to go outside or they're not going to start their exercise regimen.
(16:16):
Just that reduces the potential for irritation. Not many patients get it, but we want our patients to have success and few side effects. So that's the one take home pearl along with keeping the cap upright as they deliver the medicine into the hand to apply to the skin.
Dr. Walter Liszewski (16:32):
That's a great pearl. And one pearl that I will share as well to the audience, if you're not used to using the non-steroidal topicals, and we have many of them now available on the market, one thing to be aware about is that many big box pharmacies may not keep them in stock or it's difficult for them to get them into their store to dispense to patients. The point of that is is that if you're not familiar with using specialty pharmacies or specifically dermatology-focused specialty pharmacies, there's a variety of them that are out there.
(17:06):
They are not only great at keeping these drugs in stock, but they can also really help your practice get the medication. They can sometimes help with the paperwork and the approval for these medications, and they can be transformative for patients, but sometimes there can be barriers to access. And these specialty pharmacies can really partner with us to make accessibility for these drugs as easy as possible for our patients. So with that, Dr. Hebert, I want to thank you so much for joining me today and for sharing all of your pearls. Thank you.
Dr. Adelaide Hebert (17:39):
All right, thanks.
