PracticalDermatology

For the first time in decades, there is a healthy pipeline of new eczema drugs in development, including the first biologic drug indicated for moderate to severe eczema (see article on page 39). All this development will bring profound change for physicians. It will also bring misconceptions and bewilderment as patients, payers, medical practices, government, and medical academia all scramble to understand eczema’s changing healthcare landscape as it pertains to their respective needs.

An Evolving Treatment Landscape

Treatment of eczema should be part of a broader program of management. Proactive treatment with topical steroids or calcineurin inhibitors can relieve the inflammation associated with eczema, but the key is preventing transepidermal water loss and restoring the skin barrier. In parallel to this focus is the hallmark symptom of eczema, itch—an itch that will predictably rash once scratched, but which is likely due to underlying inflammation which is not yet visible. So while the landscape with respect to available anti-inflammatory agents has not changed too much, aside from new vehicles, until recently a larger emphasis had been on barrier repair “devices,” for example, stabilized hypochlorous acid preparations. The landscape, however, is about to change dramatically as the systemic small molecule and biologic pipeline comes to fruition.

Our familiarity with the integration of systemic targeted therapies in psoriasis and melanoma/non-melanoma skin cancer makes foresight here relatively effortless and therefore it is reasonable to say we are entering a new age in eczema management. The greatest paradigm shift resulting from the advent of these medications will be appreciating eczema as a systemic disease. Many have taken hold of the concept that systemic inflammation connects the dots between eczema, atopy, and asthma. However, this appreciation is not as established as it is with psoriasis. New medications will change our management, but our workhorses—moisturizers and barrier repair products—will still be needed, as these systemic agents are not gene therapy. The inherent defects that result in stratum corneum dehydration (filaggrin defect) and therefore altered skin pH and microbiome (a rapidly evolving area of atopic dermatitis research), decreased keratinocyte adhesion (occludins defect) allowing for increased permeation of antigens, will not be altered. Therefore, addressing the unique differences between normal and eczema skin with proper skin care will still be relevant even with these new medications

Current and Future Challenges

Several challenges face clinicians and patients in the management of eczema, however. Education of the patient and family regarding disease management education remains of the utmost importance to properly care for atopic dermatitis patients, who endure what is a chronic and chronically relapsing disease. With the growing pressures to see more patients in less time, this pinnacle component of care may be undermined and shortened. Prescriptions for topical and systemic anti-inflammatories are only a small component of eczema management. The heavy lifting is undertaken by the patient and his/her family at home. Major lifestyle changes are often needed; for example, proper soap and bathing habits, as well as environmental changes such as utilizing a humidifier, topical moisturizer and medication use, clothing fiber choices, etc. These time consuming and possibly costly initiatives can be difficult to digest and therefore partnering with the patients, being supportive, providing realistic expectations is equally as important as those prescriptions. Utilizing available resources from the American Academy of Dermatology and the National Eczema Association (www.nationaleczema.org) can lighten the physician’s load when tackling this condition with the patient.

Along the lines of cost, given the chronicity of this condition, the bills can certainly add up, with patients running out of their medications before their insurance will allow for a refill. We are in need of more topical steroids offered in larger containers as well as better training for all physicians on appropriate tube size for body surface area involved. How many times have we heard a patient complaining about receiving a 30-gram tube of triamcinolone for 80 percent body surface area? While a controversial subject, utilizing samples can help prevent delays in onset of care. To help offset costs of medications when coverage is limited or non-existent, our pharmaceutical industry partners often provide programs to assist patients in obtaining expensive medications.

The Role of Advocacy

In light of the latest innovations in this field, advocacy has become a central point in understanding and managing eczema. It is important to differentiate between the two general categories with respect to advocacy: Physician-based and patient-based advocacy. Physician-based advocacy refers to providing digestible information that can easily be incorporated into one’s day-to-day practice with respect to pathophysiology, patient education tools that make it easier to disseminate the right info with respect to disease management, and obtaining the medications that are actually prescribed. Physician advocacy includes referring eczema patients to the NEA for education, support, and the opportunity for the patient to become truly empowered around their own disease. Patient-based advocacy is where there is potential for real, practical, and game-changing impact. Now as never before, uniting physician-based and patient-based advocacy will be essential to ensure the best quality care. These united efforts will span the development of burden of disease data, to advocating eczema quality care metrics and standards of care are established to ensure new treatments are accessible and used properly, to educating insurers about the serious nature of eczema and its impacts on the health system when not treated adequately and appropriately, to education of regulatory agencies about the serious nature of eczema and needs of patients for new treatments.

A Roadmap to Advocacy. The National Eczema Association (NEA) has developed “The Decade of Eczema: A Roadmap to Advocacy” which sets forth a blueprint for change, a vision that will propel NEA into a leadership role in this new era of transformative care. Strategies and tactics, stakeholders and relationships, as well as priorities and urgencies facing the eczema community are covered in the Roadmap. The goals include the following transformation keys:

1. Break through stereotypes and build general public awareness about eczema through an orchestrated a national campaign that articulates the burden of disease in a powerful, comprehensive message.
2. Establish cross-specialty leadership to educate and equip medical practitioners so that they are better able to effectively manage eczema care.
3. Promote new community-based medical models of eczema care that are outside of traditional spheres of practice and that leverage a wider sphere of professional resources.
4. Strategically focus NEA’s investment in medical research so that it concentrates where NEA can play a unique role, and/or where the value/yield of the research has most impact.
5. Advocate on behalf of patients so that new and emerging eczema treatments are accessible and affordable.

Taking the Spotlight

To better serve our patients, we have to start at the beginning. From bench to bedside and back, the better we understand the pathophysiology, the better we can treat and counsel our patients. It is a very exciting time in eczema research, with new animal models being developed, targets identified, drugs developed, and both physicians and patients/families teaming up to better manage and control a very emotionally and physically disabling disease. Every element is needed: research, clinical care, and advocacy. Eczema has been yanked from the doldrums of pseudo-orphan diseases (orphan in attention, not prevalence), and is taking the spotlight front and center. n

Adam Friedman, MD is an Associate Professor of Dermatology and serves as Residency Program Director and Director of Translational Research in the Department of Dermatology at The George Washington University School of Medicine.

Kevin Cooper, MD is Chairman of the Dermatology department at University Hospitals Case Medical Center in Cleveland, OH. He is also on the advisory committee for the National Eczema Association.