Journal Club: New Research in Atopic Dermatitis

Dr. Neal Bhatia:
Hi, I am Dr. Neal Bhatia. I'm Chief Medical Editor of Practical Dermatology, and we're hosting Atopic Dermatitis Journal Club. We're going to do a few interviews with some experts, and I don't think there's any bigger expert than my friend and neighbor. Dr. Lawrence Eichenfield. So Larry, thanks for coming on.

Dr. Lawrence Eichenfield:
My pleasure, Neal. I'm happy to be here.

Dr. Neal Bhatia:
Good. Just going to go over a couple of articles that were recently published, and just first start off with one of these articles that talked about some practical considerations for managing atopic dermatitis, one of them just being simple nuts and bolts. We all have different ideas about how we tell patients how to cleanse, moisturize. One of the simplest questions I guess is, how long should I leave a cleanser on before washing it off? So do you have any pros from that article, if you want?

Dr. Lawrence Eichenfield:
So yeah, I mean, that article, Donald Leung and colleagues put together a real discussion, especially looking at the earlier time period of life in treating atopic derma in young children. And this is bread and butter for us in the world of pediatric dermatology because we see young kids six months, eight months of age, not uncommon with atopic dermatitis. And the questions that the family has are very straightforward, is like, why my kid have this? How are we going to get rid of it totally? And then the answer is, okay, let's tell you what to do to manage it, which is not necessarily the answers that they want.

But the general principle of good skin care is crucial because we know the inherent barrier function that's seen in many kids with very dry skin, appropriately moisturizing the skin. What's appropriate cleansing? Now, appropriate cleansing can be as simple as just using water, but generally people will use cleansers. But it is true that patients with atopic dermatitis will have more tendency towards irritant reactions as well as cutaneous allergic reactions as well. So the traditional setup products that are not harsh to the skin, not drawing to the skin. And so cleansers, generally, if someone asks how long to put them on, the answer is as short as possible.

Dr. Neal Bhatia:
Short as possible, exactly. But we know because in-

Dr. Lawrence Eichenfield:
And then rinse appropriately.

Dr. Neal Bhatia:
Yeah, because in San Diego, the water's probably some of the hardest water in the country.

Dr. Lawrence Eichenfield:
Yeah, it's really interesting about hard water. In the UK, they did some really cool studies looking at hard water and onset of atopic dermatitis, and they showed that in regions that had harder water, there was higher rates of atopic dermatitis. But when they followed it up with a big intervention study, putting people in soft water didn't change the course of the eczema at all.

Dr. Neal Bhatia:
No, it says something. It always just goes back to the same fundamental question, what do I put on first? Right? We always have the same answer. Everyone just put your moisturizer around last and seal it up. It's always an easy way to do it.

Dr. Lawrence Eichenfield:
Yeah, but I do think that a question in this mild eczema... And we don't necessarily talk about it. I think that the article was good at trying to give the whole perspective because a lot of the hot changes in atopic dermatitis or in new non-steroidal topicals and biologic agents, and older kids will come back to that with JAKs and others. But there are many kids in the first few years of life who can truly be managed with moisturizers and low level of inflammation will sometimes respond to that as well, but the general theme, the messaging that I think is so important is that if you're not better after a few days with moisturizers and you have inflamed skin, then you need an anti-inflammatory.

Dr. Neal Bhatia:
Then you get to business, exactly. Well, you mentioned biologics. I mean, now there was another article just talking about, again, the history and the progression of biologics to the pediatric group, especially now that we have six months. Obviously, we have a couple that are at 12. And what do you see with that?

Dr. Lawrence Eichenfield:
That was a pretty comprehensive article because it discussed not only atopic dermatitis, it discussed psoriasis and a little bit on hidradenitis suppurativa and chronic spontaneous urticaria. Those are the sort of disease states. They didn't include alopecia at the time that came out, but they probably would now.

But biologically atopic dermatitis, it's been life-changing for us as practitioners, one of those times where we hit a new drug or new set of drugs that bring a totally different outcome for affected individuals. And for our more serious eczema patients, it's been shockingly different than before. And to be truthful, in, I think, across the ages, but any group of ages younger and younger, whether that be adolescents as compared to adults or younger kids as compared to adolescents, the tendency was that when we had only traditional systemic medicines, they weren't used that much. It was cyclosporine, methotrexate, Imuran that we were using. And the revolution with what I call advanced systemic therapies, which will include our IL-4, 13 blocker, dupilumab or IL-13 blockers, tralokinumab right now, and lebrikizumab right behind it, already approved in Europe. Nemolizumab, probably another year from now, is the IL-31 blocker.

And then our oral JAK inhibitors, they're remarkable in their utility. So I really take that strategy of where if patients have inadequate control of the disease, you can step up. And that core message, which my spiel to families is, we really want long-term disease control. What do I mean? I want minimal rash, minimal itch, minimal sleep disturbance.

Dr. Neal Bhatia:
Exactly.

Dr. Lawrence Eichenfield:
And minimal impact for the activities in the family.

Dr. Neal Bhatia:
Because like you said, we're not only treating the patient, we're treating the parents, treating the siblings and everybody in between. But then it comes to the difficult conversation where they've heard everything on social media, they've done their homework on-

Dr. Lawrence Eichenfield:
Social media, that influences what patients are doing?

Dr. Neal Bhatia:
Oh, maybe one or two.

Dr. Lawrence Eichenfield:
Yeah, that's terrific.

Dr. Neal Bhatia:
But we also have the difficult dermatologist who still doesn't want to believe in some of these therapies. So what kind of pros do you have for getting over the hump?

Dr. Lawrence Eichenfield:
Yeah. I have a few methods that I use to try to explain to patients here, not other dermatologists. I mean, the dermatologist is different. The dermatologist is relating the data and the stories of how patient's lives are totally different. That's easy. For patients, it's a mixture of that, about how our experiences with patients and their change in life. But also what I like to do is, I say I'm unpacking the backpack of how eczema's impacted on the kid and the family. So I ask about sleep disturbance, I ask about itch, but I'm also asking about how the family's handled the rash. I ask about familial sleep disturbance because we know the data on that's pretty incredible. Any mental health things that may be going along. Also, activities that the patient may not do.

Dr. Neal Bhatia:
May not be able to swim or-

Dr. Lawrence Eichenfield:
It's so common. Even in adults and younger kids, there's things that they, work arounds that they do for the disease state. And then I also like to do the severity assessment. I like body surface area because it's a quantitative number. And I'll tell you, when I tell a family that their kid has 68% body surface area involved, they get that. That's a number. When we get that down to nothing or half a percent, they really see that. They see the difference. Yep.

Dr. Neal Bhatia:
They see the difference and they can feel it because we're talking about it.

Dr. Lawrence Eichenfield:
So severity assessment's part of the discussion because it quantifies the disease to a degree. And then we have the discussion of, what are we going to do going forward, here are the options. We can keep doing what we were doing before. If that worked, that's fine if you have adequate control. And to be truthful, we have these new topical non-steroidals that are coming into hands. There may be some patients who don't need the systemic, but when you see that life impacted and if you can't do it with the mixture of topicals, roll onto systemic injections.

Dr. Neal Bhatia:
Yeah. And like you said, you know with that surface area, especially if it's on the back or the scalp, topicals aren't going to be enough. But what's also interesting, you get these arguments about costs, cost to the system, but everyone forgets about the cost of not treating these kids and change of their lives.

Dr. Lawrence Eichenfield:
Yes. Well, I think that's where we've done a good job in the last 10 years in getting not just lists of comorbidities that are associated with the disease, but then you can see really the data showing how they impact on the individual. And really, it's been absolutely remarkable when we see our patients back on our biologic therapies or oral JAK inhibitors. Their lives are so remarkably changed, and you just see the change in their attitude, in pediatrics, especially. You could just see with the way they're handling stuff in school, people who couldn't do sports because they were sweat intolerant are now doing varsity soccer and stuff. It's incredible to see the change in lives that come along with the medications.

Dr. Neal Bhatia:
Going into JAK inhibitors is pills as an alternative to shots, or maybe some are not shot, kids, for example. I mean, we're still at 12 and up now, but there may be a day we're talking about six-year-olds.

Dr. Lawrence Eichenfield:
Yeah. So baricitinib got approved in the United States for atopic dermatitis. It's approved down to age two in Europe.

Dr. Neal Bhatia:
How about that?

Dr. Lawrence Eichenfield:
Yeah, they expanded that age. But that's the sort of thing we may be seeing going forward. There's a pro and con to this, right, of pills and biologics for a variety of different reasons. To be truthful, taking an oral medicine, you have to take it every day.

Dr. Neal Bhatia:
Every day. Exactly.

Dr. Lawrence Eichenfield:
You have to take it every day. I hear it's sometimes easier if you're doing something once a month or every two weeks.

Dr. Neal Bhatia:
Exactly.

Dr. Lawrence Eichenfield:
But of course, there's also so much concern in many patients about shots.

Dr. Neal Bhatia:
Shots, exactly, because many, they feel like they're sick, otherwise. They don't want to take shots. They equate it with diabetes or something else. But the other thing is, again, getting the parents out of their own way with the box warnings and everything else, because I showed them the percentage of the adverse events in each trial. I said, where is the drama? There's nothing here.

Dr. Lawrence Eichenfield:

So I'll tell you, one of my interesting experiences over the last three years is we set up a multidisciplinary atopic derm program. We call it the MADP, which is where we actually co-evaluate patients with allergy and dermatology. Bob Geng, my allergist and I, we see every patient. We have a clinical pharmacist as part of the clinic. We also have educators and researchers. So it's a low volume, high intensity, two-hour visit thing. But I've learned so much from it because one of the things we learned is that in taking this sort of holistic 360 degree view on the patient's condition, not just atopic dermatitis, hearing about their allergies, even though their allergies, for instance, may not be triggers of eczema at all, our ability to get to the shared patient decision making together is incredibly aided. It's just that, yeah, they're like, oh, I guess they care. They're taking more time. They're hearing about this. They're helping all the aspects of our lives or patient's lives, and it's easier moving forward. So I've learned from that and tried to bring some of that over to my regular clinics as well.

Dr. Neal Bhatia:
Well, and having the other hand of the allergist involved is going to cover all the bases.

Dr. Lawrence Eichenfield:

Well, we did it because we knew there were so many mixed messages going because you can see an allergist and a dermatologists and get totally different regimen of care, totally different stories about what's important. So trying to get people on the same page is really important.

Dr. Neal Bhatia:

No, exactly. And that-

Dr. Lawrence Eichenfield:

And that's why it's important. Actually, that article on pediatric eczema came from an allergy group.

Dr. Neal Bhatia:

That's right. Yeah.

Dr. Lawrence Eichenfield:

And it's an enlightened allergy group that knows about good skin care and about all the different needs for both topical anti-inflammatory steroids, and non-steroids, as well as our new modern systemic agents.

Dr. Neal Bhatia:

Absolutely. Well, and again, it's conversations like this for our colleagues that, again, just kind of clear the air about what really is something to approach in terms of getting conversations with patients and their parents are easier, but also the approach, inside out and outside in, I think that's a really comprehensive way to do it.

Dr. Lawrence Eichenfield:

Yeah.

Dr. Neal Bhatia:

Well, very good. Dr. Lawrence Eichenfield, thank you very much.

Dr. Lawrence Eichenfield:

Thank you, Neal. It's a pleasure to be part of this.

Dr. Neal Bhatia:

Absolutely. It's always fun to have my neighbor just doing everything fun like this. And this is another episode of Atopic Dermatitis Journal Club, and we'll see you again.