PracticalDermatology

From a clinical standpoint, what are some of the most significant knowledge or understanding gaps among both adults and children who are coming into your practice with eczema and atopic dermatitis?

Dr. Fromowitz: I think that generally patients believe that there may be a simple solution, or even a cure for atopic dermatitis. Unfortunately, it’s a chronic condition. There are cycles of flares and remission. I look at my goal as not only to educate patients to understand the disease pathogenesis, but more importantly, to try to help provide them with longer disease-free intervals and minimize the complexity of the treatment regimens that they’re using. The more complex the regimen is, the lower the compliance tends to be, and the higher the relapse rates or the severity of the flares are. We really want to improve patients’ quality of life and we find that by helping patients understand what the natural history of their disease actually is, they buy in to understanding why we talk about barrier, why we talk about skincare, why we talk about laundry care, why we talk about specific prescription repair creams and additional topical steroids, or topical calcineurin inhibitors (TCIs)—how all of these puzzle pieces fit together to create the right picture to help them do well with their disease.

There is more research coming out about the prevalence of adult atopic dermatitis and the quality of life impact of the disease across people of all ages. Do you have any tips for your dermatologist peers when talking to patients about eczema?

Dr. Fromowitz: I think first of all, in general, we think of atopy as a disease of childhood; but as we see emerging evidence suggest, atopic dermatitis can persist, and the prevalence is higher in adulthood than we previously thought. We need to consider atopic dermatitis in the differential of an itchy adult who presents to us with red scaling patches in flexural areas.

I think that one of the disconnects that we can often see is that demands of clinical practice and time constraints limit the amount of face-to-face education we can have with patients, and some of the insights we can provide during our encounters. Sometimes there’s a disconnect in the quality of the information and the quantity of the information we’re able to communicate to a patient during their visit. While we may take a little bit of extra time with a family and with a child, an adult who may be struggling with atopic dermatitis needs that same information. That’s something that I think is an opportunity where we as providers can improve.

One of the things we’ve done to help improve that is to really design some collateral materials we give patients that help detail a lot of the things that we’re talking about today, and go through some of that education to act as a reinforcer for the visit and for the discussion we have in the room.

Much of what we say in the encounter is forgotten, because it’s a higher stress circumstance or situation for the patient. We like to provide them with some take-home material to help give them some education afterward.

I really think that primarily, we just need to consider atopy, that it not only is a disease of childhood, but it’s one that can persist or occur in adulthood, and that taking a little bit of extra time to educate helps patients do much better and have better outcomes and fewer call-backs.

What have you found to be some of the more effective tactics for getting through to patients in the setting that you describe?

Dr. Fromowitz: First of all, I think that repetition is the mother of all learning. After we go through the entire visit, I summarize all of what we’ve discussed a second time and review the highlights of the disease state and its management. When I leave the room, my nurse reviews the prescription and does that same process again. So it’s three times they’re hearing the information, because there’s some data that suggests that when you hear something three times, it helps improve your recollection or your retention of that information.

We have disease state collaterals that we give patients. Those outline things as simple as bathing techniques, water temperature, emollient use, the function of anti-histamines, how we use topical steroids, how we address flares, what to expect at your treatment, when to call the office if things aren’t going well, what to look for, what to expect.

We’ve found by doing this that we have dramatically enhanced patient compliance with our regimens. By improving compliance, we’ve dramatically improved our outcomes. Most importantly, we’ve improved our efficiency in the practice, because we’ve really minimized the patient callbacks for a lack of understanding, questions, uncertainty about what to do when or how. Really providing that printed material is so beneficial. The other thing we do is recommend resources online, like the Atopic Dermatitis Foundation website and things of that nature. Depending on the person, sometimes we help drive them to some of those resources as well.

Are there any other technologies or tools that you recommend to patients, or that you’re using to communicate to them?

Dr. Fromowitz: Integrated in our electronic medical record, we have a portal. We have an ability to communicate with patients. We frankly encourage an open exchange, not only through our portal, but also I’m a believer in follow-ups with patients. I think that when you’re managing chronic disease, it’s not a “set it and forget it” mentality where you may see them every few months. When we’re dealing acutely with a flare, with a new onset diagnosis of atopy, I tend to see the patient back at a two-week follow-up. At that interval, we not only assess how they’ve done with the regimen, but also offer them reassurance and further guidance, and to, again, revisit those fundamental lessons we discussed at the first visit .

Something we forget with adults in atopy is how impactful it can be on quality of life. We’ve got tremendous data now in the psoriasis literature that shows how impactful psoriasis is on the quality of a person’s life, their rates of depression, the impact on solitary behaviors, and withdrawing from socialization. Atopy also is a disease with terrible itch, with unsightly skin changes, with dryness, irritation, burning and stinging; also having significant impact on a person’s quality of life. When we can restore and improve quality of life, that’s such an impactful change for our patients.

I think there might be a disconnect in some clinicians’ understanding of how impactful pruritus, burning, and stinging can be on a person. Chronic itch can be debilitating, much like chronic pain. I think that might be an area that people don’t always keep in mind when they treat patients with atopic dermatitis and sensitive skin.

Do you have any pearls that you like to share with patients in terms of helping to manage symptoms?

Dr. Fromowitz: As we understand more about atopic dermatitis, we understand that fundamentally, it’s a breakdown in skin barrier function. When skin barrier function breaks down, it increases itch, dryness, redness, inflammation. When you’re able to improve the hydration and barrier function of the skin, you’re able to increase disease-free intervals.

We’ve really integrated an understanding of inflammation and barrier function into how I practice. Since I’ve done that, I’ve gotten dramatically improved results in our patient outcomes and in how successful our patients are at managing and treating their disease. We really truly in all of our patients address barrier function. In doing that, we use different barrier repair creams. We offer tips on how patients bathe: lukewarm, never hot water. We talk about the impact of Staphylococcus aureus and colonization of the skin, and eczema flares. We utilize bleach-type washes. There are some of the newer products on the market like the Cln line, that has hypochlorous acid derivatives in it. I explain it simply like a low potency bleach bath. It’s kind of like the old paradigm of doing bleach baths for atopics. It’s a really nice alternative that patients can use to help cut down on the staph living on their body.

I think as a barrier repair cream, EpiCeram is an outstanding option. It’s a three-to-one-to-one ratio of ceramides, free fatty acids, and cholesterol. By using it, fundamentally, at the functional level of the skin, it can repair the skin barrier. You can improve antimicrobial peptide function. You can decrease Staph colonization. You can decrease inflammation. You can provide longer disease-free intervals. All of these simple changes like the wash, the barrier repair cream, the integration of antihistamines if pruritus is a component at night, all of these little simple changes go far beyond just prescribing a topical steroid for an eczema patient and can make a big difference in their outcomes.

I think fundamentally as a practical tip, I would summarize by saying that it goes beyond just topical steroids, TCIs, even crisaborole, which is marketed as Eucrisa, a new agent for atopic dermatitis. Rather, there’s more to it than just you’re active sympromoloy. “Inactive” aspects like barrier function or Staph colonization matter and have significant impact on disease state.

Especially for adults who are potentially dealing with itch and other symptoms for quite a while, it would seem that they want a solution, but do they ever bristle at receiving a diagnosis of a chronic disease that they didn’t expect? If so, how do you deal with that reaction?

Dr. Fromowitz: I often will tell patients, “Look, as I’m looking at you, this is what it appears to be. And I understand that our goal or your desire as a person is to come in, to be given a label, and to be given a cure or a solution. I wish I had that tool available to me, the reality is that unfortunately, that tool doesn’t exist.

“What I can provide you with are several tools that will help take you toward that goal, with our hope being that small and easy changes moving forward, be it just what soap you’re using, how you’re bathing, what you’re putting on your skin after a shower, little tiny changes that will be insignificant in your grand scheme of life, will allow you to be symptom free. Having said that, there may be times where those aren’t enough and you’ll have a flare, and we’ll go to plan B where we use other tools to help your skin and to help control things.”

That’s how I approach it. I try to be non-confrontational. I try not to disagree with them. I try to acknowledge their frustration; because they’re not coming from a desire to challenge what you’re saying. I try to empathize with their circumstances, understand where they’re coming from, reflect back to them that I get it and I understand it, walk them through how we’re going to address it. Then in those patients especially, I find that close follow-up helps

I really find that the best tip I have is to be non-confrontational. I don’t get upset. I don’t fight back. I don’t push. I don’t get into a struggle of wills, if you will, to try to show that I’m right and they’re wrong. That just goes nowhere. I think many times, it’s just people want to be heard. They want you to understand that they’re frustrated and they don’t want to “have a disease.”

Graphically Speaking

Laundry care for patients with sensitive skin tends to be a topic that we don’t really talk about. There’s a lack of very reliable, concise, vetted information to provide really good resources for these patients. We thought that it would be important to provide patients with guidance so they can make better and more informed decisions, and improve their skin health. I think that when you provide patients with a nice infographic that includes not only data but pictures and quick tips, it helps make the message a little bit more impactful. More importantly, it provides them with a central resource that goes through a specific part of their disease state management.

It’s better than a simple Google search, where someone goes online and types in “sensitive skin laundry care.” Instead of a hodgepodge of tips from various sources, we’ve prepared a thoughtful infographic that helps those patients who suffer from atopy or sensitive skin to know what are some good choices for laundry care. What are some things to look for? What are some things to avoid? How does laundry care and topical irritants impact my disease flares and my disease free intervals?

—Dr. Fromowitz