Transcript
Brad Glick: Welcome to Practical Dermatology Roundtable. I'm Dr. Brad Glick and I'll be your moderator today. I'm a board certified dermatologist and I practice in South Florida. Today we're going to be talking about retaking CSU, why dermatologists should reclaim the management of chronic spontaneous urticaria. Joining me today are two experts in the area, Dr. Laura Ferris, who is chair at the University of North Carolina Chapel Hill, and Dr. Larry Green, who's in private practice in Washington, D.C., and he's also a clinical professor of dermatology at the George Washington University School of Medicine, and also serves as our vice president of the American Academy of Dermatology. So to both of you, welcome. Thanks for being here.
Laura Ferris: Thanks for having us.
Lawrence Green: Yeah, of course.
Brad Glick: So let's jump in right away and let's talk the obvious question, and that is how did dermatology lose urticaria? What happened, Laura?
Laura Ferris: I think there's kind of a lot of facets to this. So one, I think when we didn't have great treatments, it was really kind of a drag to have these patients because they were so unhappy, so uncomfortable, and we couldn't do a whole lot. Then we finally got omalizumab, but it became hard to give in that you had to give it an office setting, you had to monitor patients. That was outside the normal workflow for a lot of dermatologists. And then I also just think patients felt like there must be an allergy, there must be something. I just need an allergist. I need them to get to the bottom of it. I've got to stop doing what I'm doing and this disease will go away.
Lawrence Green: Yeah, I'll add to that, Brad. I think it's where we were maybe 30, 40 years ago when we would see a severe patient with psoriasis or HS. No one wanted to take that patient because there were no treatments. And you look at chronic CSU, which is what is now what psoriasis was 20, 30 years ago where there were no great treatments. Now there was no one else to treat psoriasis back then, so it was us, but a lot of us didn't want to treat psoriasis even at that time because it was so difficult. So the same thing, I think we lost CSU down the path because there was no great options. So what can we do for the patient? The only thing to do was refer them to an allergist for allergy testing, which is usually fruitless, but it gave us to tell a patient something to do. And that's no longer the case. So it's very important I think now to reclaim it.
Brad Glick: For me, I would add that our focus this last 20 years has been on inflammatory skin diseases like psoriasis and atopic dermatitis because finally those therapeutics did come into our toolbox. And I think for us, just like Laura said, even though we had omalizumab, there were some challenges with that as well too. Not so easy to use monitoring the patient in the clinic, like you said, but our therapeutics for psoriasis and of course more recently for atopic dermatitis have made it easy for us to manage those patients and that was kind of our focus. But I think now that we have tools in the toolbox, it's kind of great that we can have a little bit more of a focus on CSU.
Lawrence Green: Yeah, I'll make the analogy even further. Omalizumab reminds me of Enbrel, for example. It was the first of a great medicine we had to treat psoriasis and then things sort of snowball. We have much, much better medicines, which I see coming with CSU as well. So while Enbrel was effective, it required monitoring, there's TB testing. It was something new that a lot of dermatologists were unfamiliar with. And I see the same thing with omalizumab that's affected the way we treat it, but things are getting easier. We really need to reclaim it.
Laura Ferris: And I'm going to jump in and even say I practice at an academic institution. My institution decided that dermatology could not administer omalizumab; allergy could. So I just think about the person in private practice maybe who's not connected to a hospital. And if my own institution's pharmacy group doesn't agree with it, decided that dermatology shouldn't be giving it, can you imagine being a standalone dermatology practice thinking, "Sure, I'm prepared to manage the possible, although very rare, side effects of the drug."
Lawrence Green: So we're perpetuating the myth.
Laura Ferris: Yeah.
Brad Glick: It's such great points and it's so interesting because I think all three of us work in slightly different practice models, but I think more recently, because with OMA, now you can treat the patient in the clinic and then lessen the amount of time that you keep them there and then they can self-inject at home once you feel that that potential small risk of anaphylaxis that we glean from the clinical trials is no longer really present or available. So we talked about allergy, allergy departments. What about allergies? I mean, what about CSU? I mean, is it an allergy? Because I think that that's where some of the confusion comes. This is a chronic condition. Was it really an allergy, Larry?
Lawrence Green: No, it's not really an allergy, but the myth, again, perpetuates for some reason. Patients thinking I'm in private practice, they always want to find an explanation, an easy explanation for their hives, for their urticaria, and especially chronic urticaria because they've had it a long time. So they're always looking for the easy answer. We can do some basic labs like a CBC or sed rate, but we don't do allergy testing and they want something. And that I think is the issue because allergy testing is usually fruitless, doesn't get you anywhere. But as someone in private practice, you want to make the patient happy. And unfortunately, this is really not the right path to go necessarily. It doesn't help them.
Brad Glick: That's a good segue to the how. How do we work these patients up? What do we do? What are the first steps and what are your approaches?
Laura Ferris: So mine's really simple. I ask them, "Oh, you have hives? Did you start a new medication?" "No." "Okay. Is there something that you can directly tie to this, like ‘I never ate strawberries before, now I do, and I got hives?’ Fine, let's try cutting that out." Other than that, there's really no testing to do. This is CSU. It's been going on for six weeks or longer, and there's no testing. I don't do blood work. I don't send them for allergy testing. Yeah, I take a good history obviously, but to me, this is also why we can reclaim this because there's not a complicated workup and a lot of things to think about. Get a good review of systems, if something stands out, obviously work that up. But for the average person, I'm not doing a workup.
Brad Glick: Dr. Green, anything to add?
Lawrence Green: 100% agree. Keep it simple.
Brad Glick: Yeah, it's interesting. And I think those that are doing workups and doing laboratory testing, it likens to me the analogy of patients even with chronic hand eczema. You could do patch testing on them, have them stop their treatments, whether they're systemic or whether they're topical therapies. Now you're delaying their care when they could have had care. We have targeted therapies for that now too. I think it's the same principle with CSU. And now with tools in the toolbox, besides the primary therapies are antihistamines, which we can talk about that, we now have three pretty darn good choices that we can initiate right away and none of them require any lab testing as therapeutics even to begin with. So, I think that that is exceptional for our patients so we can start them right away. And I handle this very much the same that both of you do as well.
