Healthcare Disparities and Patient Burden Associated With Atopic Dermatitis

And to get us started we are actually going to hear from a patient about their lived experience with atopic dermatitis. Let us watch.

[00:17:31] Patient Perspective

Speaker: I was diagnosed with atopic dermatitis when I was just about 2 years old, so over 30 years ago. And growing up with eczema, it was on the moderate to severe side. So it impacted every aspect. I mean, I remember missing days of school, going to the nurse's office all the time, walking around with either an ice pack in my hand, carrying my creams everywhere I went. It was literally something that impacted me from the moment that I would wake up to the moment I would go to sleep, and even in interruption of my sleep pattern in there as well. But it impacted every aspect of my life, literally.

Victoria Garcia-Albea: So we are going to hear from this patient a few more times throughout the presentation. And I wanted to mention, we do have a Q&A option available. So if you have questions throughout the talk, just type them into the Q&A section on your Zoom thing, and we will try to get to as many questions at the end as we can.

I am going to hand it over to Dr Lio to take us through some of the breakdown of atopic dermatitis.

[00:18:25]

          Epidemiology, Pathogenesis, and Comorbidities

Dr Peter Lio (Northwestern University Feinberg School of Medicine): Thank you so much, Tori, and welcome, everybody. Thanks so much for joining us tonight. We are going to talk about the epidemiology, pathogenesis and the comorbidities for atopic dermatitis.

One of the things that is really frustrating for me is that people who are not in the know, they will dismiss this as just being a little rash. But we know, first of all, this is a heck of a lot more than that. We know it affects on the order of up to 20% of children. Some of the most recent surveys suggest just a crazy number of patients affected. Most common onset is between 3 and 6 months of age.

And we know that about 85% of the patients develop it by age 5. So it is predominantly a pediatric disease. But many of my adult patients are frustrated because they were told for years, do not worry, you will grow out of it. And we now know that up to 60% of cases can persist into adulthood, and adults can get it de novo. One in 4 adults with atopic dermatitis report adult onset of their symptoms.

So these are, I think, really important things to keep in mind. We never want to give a false sense of hope that, just wait it out or it is going to disappear. Or now that you are 6 years old, it is never going to happen, things like that. They do not age well.

It is characterized by cycles of flaring. We get these worsening symptoms and then improvement, relatively speaking. But we know that in the real world it is complex. Patients with moderate to severe atopic dermatitis have around 7.5 flares per year, and three quarters or so experienced either no remission at all or less than 3 months of remission in the previous 12 months.

So even though it kind of waxes and wanes, it is not like it totally disappears for a lot of patients. They go from bad to worse, bad to worse, but maybe never get really good.

[00:20:07]

          Epidemiology of AD in Racial and Ethnic Minorities

It turns out that we know there are some imbalances that are happening. Those living in urban areas are more likely to have atopic dermatitis than those from rural or suburban areas. And there is a higher prevalence of atopic dermatitis in Black children in urban areas.

Now, this is important because there may be some really important aspects of social justice happening, too, that we think pollutants in particular may be playing a role in things like car exhaust. And we know that depending on what kind of neighborhood you live in, there can be more lax environmental regulations that happen in poorer communities. So this is not necessarily all due just to race by itself as an independent variable.

There often are other socioeconomic aspects that go along with this, making it really complex but a really important problem.

[00:20:53]

          Social Determinants of Health

And this really speaks to this concept of social determinants of health. We know that things like economic stability, the neighborhood and physical environment, education, the food, the quality of food that we are eating, we think that does play a role, of course, in health outcomes, community and social context in the healthcare system, all come together to lead to this complex matrix of health outcomes, from morbidity to mortality to healthcare expenditures and health status and all these functional limitations.

So I think we just put this here to say that we understand this is not a simple problem. This is really complex, and I wish we could just solve it with a magic wand, but it is not going to be that easy. There is a lot of pieces to this puzzle. But if we do not start, if we do not talk about this, then we are never going to get there, right? That is the one thing I think we are all sure of.

If we never even try to get into this, then we will never get there. And we just have to understand that it is probably going to be some time in pretty complex, and we have to do our best to keep learning about it and keep pushing, because we know there really are disparities.

[00:21:51]

          Impact of Health Disparities on AD Outcomes

So it turns out that racial and ethnic minorities are more likely to have treatment-resistant atopic dermatitis to experience poor social determinants of health.

And we know this is correlated with:

• Lower socioeconomic status
• Living in older homes or across multiple homes
• Having a lower education level
• They can have impaired quality of life, which we know.

Again, this is across the board for atopic derm, but it seems to be more likely in racial and ethnic minorities.

And we know that Black and Hispanic patients have more moderate to severe. So on that more severe spectrum of disease. And more atopic dermatitis related office visits for Black and Asian children.

[00:22:26]

          Access to Dermatology Specialists

So this is important that we really see this. And of course this is against the backdrop of something that seems to really belie all of that and work against us, because we know that access to dermatology specialists is also not equitable. It is not sprinkled perfectly throughout the nation. We know that in smaller population areas, we do not see nearly as many dermatologists. We know that it is not as available to people that are impoverished.

And we understand that, that it can be really tricky, especially because those tend to correlate, unfortunately, in the United States with race. We have a lot of patients who are in underserved areas that are also minorities, and Black and Latino patients have less access to dermatologists even in their county. Native American, essentially 0% have access to a dermatologist in their county.

So we talk about a lot of this access issue for derm. It is a problem across the board. But it is even intensified for these populations. And of course it is just like insult to injury that these populations also have more significant disease, and more hard hitting ramifications that we are actually seeing there. These impacts are even larger.

[00:23:38]

          Impact of Environment on AD

Of course, we understand that this environment plays a role on atopic derm as well. Stress undoubtedly is connected with this condition. It can trigger symptoms, it can trigger a flare-up. And we know that strong social support can be a benefit. Again, you can imagine higher stress levels in underserved communities and less of social support sometimes for people that are living under the poverty line or trying to make it from paycheck to paycheck, things like that can really push people to the limit.

We know that diet has an important impact on our overall health and on our skin. And while maybe not as simple as just avoiding a food or foods, we know that highly processed foods seem to push people towards inflammatory states. And of course, the anthropogenic aspects, air quality and pollution. And currently, there has been a flurry of papers and interest around this idea that there are particular pollutants that are in the environment that seem to be correlated with atopic dermatitis, damaging the barrier, damaging the microbiome.

And that has been kind of an exciting area because I think up until very recently we have not talked about it in these terms. So I would argue this is absolutely the cutting edge. And of course, whether or not you acknowledge climate change being due to humans or not, I am less interested in getting into that debate because the truth is, I think we all agree. Everybody agrees that climate is changing.

So even if you do not give much stock to that, that is okay. We know it is changing. And we know with the change is going to come higher temperatures, more UV, higher humidity and probably a rougher environment for these patients. So we have a lot of work to do.

[00:25:06]

          Economic Factors Impacting Black Patients

We also know some of the economic factors that are involved with every patient. But I think particularly impacting Black patients.

We know Black patients with atopic dermatitis were:

• Younger
• Had a lower household income
• More likely to have Medicaid coverage
• More likely to live in an urban area
• Had poorer control of atopic dermatitis
• More frequent skin infections.

We also know that it is correlated with higher out-of-pocket costs for prescriptions and generally not having prescriptions covered. And thus, as you can imagine, if that is the case, an increased number of emergency department visits sounds pretty reasonable. If you are having trouble getting in and having trouble getting things covered, you are like, well, the one outlet that we have is to go to the emergency department. And this is really important to know because there are higher odds of harmful financial impact and increased out-of-pocket costs to a condition that already has too much for patients, right. It is already brutal, and it just gets intensified.

So I am going to turn it over to Terry now to take us through the next step.

[00:26:03]

Evaluating Atopic Dermatitis in Patients With Skin of Color

Terry Faleye (Dermsurgery Associates): Awesome. Thank you so much, Dr Lio. So we are going to go ahead and just really kind of dive into atopic dermatitis in those patients with skin of color. We are going to go ahead and really go back to our patient that we heard from lovely before and really hear the impact of the healthcare disparities in regards to just her dealings with atopic dermatitis.

[00:26:22]

          Patient Perspective

Speaker: Healthcare disparities have definitely played a role in my experience and journey living with atopic dermatitis. I mean, I will say that even growing up and going to our doctor, they never really talked to me about what was happening, why it was happening, the triggers involved, ways to manage it. Even when it came to my skin tone, I would realize that my eczema looked very different than what I would Google online, but there was never a conversation around why it looked different.

It was always, “Okay, you have eczema or atopic dermatitis. Here is the prescription and go about your day”, vs when I met people from my community who had similar experiences, they would talk about the differences in their conversations with their doctor and how they were able to provide them just adequate resources for them.

[00:27:48]

          Case Study: Steve, 37 Years Old

Terry Faleye: So we are going to go ahead and dive into our first case study, and it is going to be talking in regards to Steve. So Steve is a 37-year-old African American male, obviously that was diagnosed with atopic dermatitis early on so far as in early childhood, but worsened at age 15. So it goes back to what Dr Lio was talking about times you have those patients that have been told that they were potentially going to outgrow it as time has gone on. And here is a case presentation in regards to that.

So we have past medical history obviously consistent with anxiety, depression and hypertension. But a lot of times I think it is really important that we look at the social history in regards to these patients. I mean, taking a look at this patient has missed many days of work and just difficulties so far as concentrating and making a lot of mistakes, honestly, which could be detrimental depending on what kind of job that he actually does.

But at the same time unable to exercise, the fatigue that is associated with it, but increased flares from sweating. And so we recognize obviously has Fitzpatrick's type V, generalized xerosis.

But I think the biggest thing that we can really take away is that obviously the clinical presentation of it. We recognize, obviously the hypopigmented so far as plaques with follicular prominence. And really taking into to note that this patient had at least greater than 85% BSA so far as involvement and hypopigmented patches.

Obviously, involvement so far as the flexural surfaces which were very lichenified and obviously mild ichthyosis so far is on the anterior shins.

I think you could take away honestly, when we are looking at Steve's case is recognizing that him saying I have been to so many doctors, primary care doctors, dermatologists and it does not matter, they have not listened to me, and nothing has helped.

And I think sometimes when we are taking into consideration many African American patients many a times, or even skin of color, a lot of times they feel like they have gone to doctors and doctors, and because they have gone numerous times to different healthcare professionals and not been able to find a diagnosis of what is going on, or to boot, they know that they have AD, but then at the same time have not received adequate treatment and are really frustrated.

So we have all had those patients that come into the door and at their wits end. But I think the real takeaway is that this patient saying, you know what? I am tired, I am scaly. And honestly, in African American terms, a lot of times we call that ashy. He is like, “Man, I got all this ash on my arms and things like that”.

[00:29:59]

          Poll 2

So now we are going to go into our poll question. And it is being which aspects of Steve's clinical presentation of atopic dermatitis are more common in patients of skin of color? So you want to go ahead and select all that apply.

1. Eyelid dermatitis
2. Hyperpigmentation
3. Pruritus
4. Violaceous erythema

So go ahead and make your selection.

[00:30:33]

          Poll 3

And so poll question number three is going to be, which of Steve's conditions are common comorbidities in patients with atopic dermatitis? So select all that apply again.

1. ADHD
2. Anxiety
3. Depression
4. Hypertension

Alrighty.

[00:31:01]

          Clinical Presentation Variability

So one thing that we definitely have to really recognize is that when we are talking about clinical presentation, it is really important, especially when we have those patients that have come into our office and have said many a times that they felt like they have been misdiagnosed or honestly do not even know what is going on. But the variability in clinical presentation is relatively really important, knowing that the variability in itself is based on age. And at the same time, obviously there is variability based on skin of color as well too.

So when you are taking into consideration those pediatric patients where you have the ones that have those cute chubby cheeks, and definitely they have so far as the accentuation so far, and the flexural creases and the folds and the extensor extremities.

But then obviously when we get to adolescence, we definitely have a little bit more facial involvement, definitely a little bit more lichenification and more plaques so far as within the neck and the palmar soles. But then obviously with adults, it is a case where we do have those patients who potentially may present so far that have had AD for a long standing period of time.

And those patients too that you have those latent onset patients. But either way we definitely have those flexural creases involvement, at the same time evolving so far as the dorsal hands as well as so far as the feet.

[00:32:06]

          Presentation on Varying Skin Tones

But I think the biggest thing to really take away is that the variability that we see in skin of color. Many a times, obviously skin of color, you definitely have so far as in what brings patients into the office obviously is the itch. But sometimes, honestly, a lot of times the hyperpigmentation so far as is of concern, definitely when we see it in other disease etiologies that we deal with in the derm landscape, sometimes that is what brings them to the door.

But it is recognizing, so far as that post-inflammatory hyperpigmentation that is present. And not only that many a times so far as the eruptions in regards to their atopic derm tends to be more papular. It tends to be more follicular so far as in nature, vs those patients that are Caucasian tends to be a little bit more pink and erythematous. That can definitely sometimes can be confusing, especially when you are looking at patients just to make sure what is going on.

So I always say that pictures tells a thousand words, what are we looking at. So this picture to the left is really just denoting when you are looking at patients that are Caucasian vs those patients who are African American. You see, so far as an African American patient, you are seeing so far as that lichenification, you are seeing so far as the hyperpigmentation. And even sometimes you are seeing so far as that ashiness that is present as well too.

Many a times those patients have had long standing disease, or sometimes you can have that waxing and waning that happens over time. But not only that, we see what that hand appearance looks like so far as the excoriations, as well as far as the sometimes those fissures, so far as to the palmar surface, sometimes when you think about those patients, how are they working so far as when they are wanting to shake somebody's hand, how does that presentation even look like?

So here we are looking at the same time, Asians vs White. And a lot of times obviously it is remembering that Asians definitely fall into the category of skin of color as well too, where many a times someone would think, okay, well, maybe it looks more erythematous, just like I would see so far as in Caucasian skin. But in truth, you definitely see more of a violaceous picture as well too, more hyperpigmentation so far is involvement.

And sometimes, depending on what you are looking at, you definitely have to make sure that when you are crossing off and looking at differentials, you are definitely taking into consideration, knowing that you know what? I am looking at atopic and I am looking at skin of color, there are variability so far as in what I am looking at.

[00:34:10]

          Comorbidities of AD

So when we are talking about atopic dermatitis, it is recognizing the comorbidities at play, it is recognizing that I know that in school it is a case where we are always kind of heard on the background, okay, patients who had atopic derm potentially had an overlapping existence of asthma as well as allergic rhinitis, and you just thought about AAA. But in truth, you are just really just recognizing that, just like Dr Lio was talking about before, many a times we have all these preexisting, whether it be environmental, so far as exposures that are going on. Definitely, whether or not anybody believes in climate change and different things like that, all those add in so far as to the conundrum, especially when we are talking about allergic so far as conditions.

But it is recognizing, I think when we talk about comorbidities, we are really just talking about the fact that we are not just dealing with a disease that is just skin related. It really tells us when we are talking about metabolic disorders, even cardiovascular disease, someone would think, okay, how does that even interplay so far as atopic dermatitis. It is recognizing that we really are dealing with a chronic immune-mediated so far as disease process. So that is when we are talking about so far as alopecia areata and so far as the overlap that may sometimes be there.

And not only that, the mental capacity that comes along with these disease processes. You think about the fact that you are not sleeping, you are not eating, you feel like you have gone from doctor to doctor to doctor and not had any results, even to boot. That is what we are talking about adults.

Even sometimes for these little bitty kiddos that sometimes cannot even express the magnitude of the impact of disease that is happening on them, is recognizing that that is where that ADHD so far as plays into place. Or even so far as autism and spectrum so far as disorders.

So it is recognizing definitely that the comorbidities that exist, of course, with the atopic dermatitis landscape is huge. And not only that, just it largely impacts so far as the disease in regards to these patients.

And so I am going to go ahead and turn it over to Dr Lio. He is going to go ahead and talk about the clinical assessment tools.

[00:36:06]

          Clinical Assessment Tools

Dr Lio: So there are a number of ways that we can try to assess the severity of atopic dermatitis in clinic. And most of them, it turns out, are really not great because they are cumbersome. They take ideally some specialized training. And part of the problem is that they do not often capture all of the pieces that we want.

So one you will see in almost every single study done in the US, for example, let us say a new atopic dermatitis medicine is the EASI score, Eczema Area and Severity Index. It is great. It goes from zero to 72, but it splits the body into these 4 areas. And it looks at erythema and edema or population excoriation and lichenification. And you have to add them all up and multiply them. It is crazy. So it is really cumbersome.

And it really only looks at the patient's skin, which you can see in that exact moment, so it does not talk about sleep or itch or quality of life.

IGA, Investigator Global Assessment is the other one that we see in almost every study in the US. And again, it is great, but it is same limitation. This one is just from 0 through 4. So clear, almost clear, mild moderate or severe. It does not even include body surface area involved. So you could have a severe patient which is hands. And you could have a severe patient who is erythroderma. And from an IGA standpoint, they are the same which is a little confusing. So they are not great.

Better is the SCORAD, which is used in a lot of European studies. It is also pretty cumbersome, but it does actually address itch and sleep.

And then my favorite of the traditional ones is called the POEM, the Patient Oriented Eczema Measure. It is 7 questions. It takes about a minute or so to do, and it really captures a lot more of the patient reported outcomes. It is asking about sleep. It is asking about itch. It is asking about an impact on quality of life. So I think that is really important.

[00:37:49]

          Atopic Dermatitis Control Tool: ADCT

There is a more modern version of it, in a way. It is a separate thing, but it is very, very similar, if you look. They are very clearly inspired by it, and it is called the Atopic Dermatitis Control Tool.

I am an evangelist for it. I have no conflict of interest with it. I did not even help develop it in any way. But when I learned about it, I am like, okay, this is what I have been looking for, for years. It is validated. It is super brief. This one takes under a minute to do. It is 6 questions, and it is so great because it addresses the overall severity, the frequency of itch, how much it is bothersome to the patients, impact on sleep, impact on daily life and impact on mood and emotions.

It is great. You can do it with the patient. I like to read through them together again. It just takes about a minute or they can do it themselves.

[00:38:32]

          ADCT Measurements

And one important thing is it is not really a severity measure though, but I think that that is actually an important part of the discussion. Because moving forward, I am much less moved by how severe your disease is, because that does not have much meaning to me.

I made a lot of patients who maybe would only be like a moderate on an IGA score when I meet them. So they are not super, super severe, except they are on 12 different medicines and have seen 6 different specialists. So it is like, okay, you are pretty severe and refractory, even though the point estimation of your disease severity is not severe.

On the other hand, I meet some patients that maybe look kind of more mild, right. And I am like, well, what is going on? And they are also being very refractory. So you have these funny things where the actual severity score can trick you. And that is why control I think is a better question. It is freely available online and you can check it out. I highly recommend getting into the habit of doing it with your patients. Below Seven is considered in control.

I am going to turn it back over to Tori, to take us through the next section.

[00:39:27]

          Posttest 1

Victoria Garcia-Albea: Thanks, Dr Lio, I am glad you disclosed that you did not create this tool because I know you really love it. Okay, so this question we are going to have you answer and then we are going to discuss the answer.

So a 24-year-old Black patient presents with complaints of ongoing pruritus despite visibly clear skin after using topical corticosteroids. Which of the following tools would best assess patient reported symptoms related to moderate to severe AD in patients with skin of color in the clinical setting?

• The ADCT
• The EASI
• The IGA
• SCORAD

Go ahead and select your answer now.

[00:40:10]

          Posttest 1: Rationale

All right. Let us see how people voted. Nice. So 66% of you responded the ADCT and the other big chunk was 24% voting for SCORAD.

So I am going to open it up to my cofaculty here. But we kind of preferred the ADCT as you might have gathered from the previous couple of slides. I think that what Dr Lio was mentioning about asking patients how they have been and not just taking a snapshot, how are they at this moment.

And I think some of this comes from psoriasis, like what you were saying. Some of our patients with psoriasis would have such mild disease. They might be on something and you are like, you're so much better. And they are like, but I still am miserable because I have 2 spots. And there was this huge disconnect. And I think there is a wonderful movement to really involve the patient's opinion, which we maybe did not do so great a couple of decades ago. And now we are really involving their quality of life. How are they sleeping? How are they able to function in their life?

Itch and sleep are so important obviously, in this disease. And remember that EASI and IGA do not assess itch at all. SCORAD does. It is a little more, I think, maybe cumbersome. Dr Lio, what do you want to add?

Dr Lio: The only thing I just want to underline and emphasizes is that in more richly pigmented skin, using erythema as one of the ways to diagnose severity, which is what of course the EASI score does and the IGA score does, and even the SCORAD to some degree is a little bit fraught. We have to be careful because if you have more richly pigmented skin, that erythema looks less intense.

If you are very, very pale, then you can see that. But if you have more melanin, it absorbs it. So I think there is a real risk of underdiagnosing the severity of disease by saying, it does not look that red. We know it can look more violaceous, but if your eye is not trained to that, you will then systematically decrease the severity because it does not look as red as on somebody who has very little melanin in their skin. And that is another reason I like the patient reported outcomes.

Victoria Garcia-Albea: Do you think it is easy to mistake erythema in people with more richly pigmented skin for PIH when it is actually active disease?

Dr Lio: That is another piece. You are absolutely right. It can be right. If there is PIH, then it can be confusing sometimes. Again, some people are very comfortable and are used to seeing it. But somebody maybe who does not have a lot of experience with a range of skin tones might sort of say, this looks different to me. I am not used to this. And I think what is nice about making a PRO, that is a universal language. The patient is going to tell you how they are doing.

Victoria Garcia-Albea: Good. All right. So Terry, anything you want to add?

Terry Faleye: No, I totally agree. I mean, I think that at the end of the day, I think, patients, they want to be heard. They want to be listened to. And so I think that when we are taking that into consideration, when a patient's telling us, okay. I can look at someone and say, okay, well they only have like 5% BSA or 6%. And you may consider that to be moderate, but in truth, that patient is just like, no, this is severe because I am not sleeping. My quality of life is hugely affected.

So I think when we look at the whole picture and the whole patient, I think it really does change our treatment algorithm just altogether.

Victoria Garcia-Albea: I think you bring up a really good point about being heard, and we are going to talk about strategies for building rapport with patients, but I think that is so important. And I think involving patients in like assessing their severity really helps to build that trust. So we will come back to that.

[00:43:51]

Addressing Healthcare Disparities in Atopic Dermatitis

All right. So here is what we just talked about. And so we have covered some background on the impact of disparities on our patients with AD and our assessment of AD in patients with skin of color. So we are going to move on to strategies to address those issues. We are not going to leave you hopeless. We are going to help to address those issues.

So we are going to hear from our patient again. Here she is.

[00:44:17]

          Patient Perspective

Speaker: I did not know there were other therapeutic options for me until I was way into my journey with atopic dermatitis. So 22 years later. I was only given one treatment option for my eczema, atopic dermatitis, growing up. And so my doctor never really talked to me about the variety of treatment options that existed. I never even knew about clinical trials or just different therapeutic areas.

Like, I just did not know that there were more options to me available at that time that I know now. And that is definitely something that I wish my doctor would have spoken to me about that.

[00:45:06]

          Case Study: Steve, 37 Years Old

Victoria Garcia-Albea: Yes, it is so important to hear our patients. And she has been dealing with this for 20 years, so she knows what it is like to go through a less than ideal treatment from her providers.

So we are going to bring back Steve, our case study. So he comes back in with moderate atopic dermatitis still affecting his work and his quality of life. He remained symptomatic despite optimized non-pharmacologic treatments like not using dryer sheets and taking cool showers and using moisturizer and everything, and the use of different topicals over the years. And he is motivated to start a therapy that will really finally get his symptoms under control. So we are going to talk about what is the next best step for Steve.

[00:45:55]

          Poll 4

All right. So we have another poll question. In what ways might healthcare disparities have affected Steve's atopic dermatitis care. And in this one you can select all of the above or whichever ones you like.

1. Underappreciated severity
2. Delay in starting systemic therapy
3. Uncontrolled comorbid conditions

So go ahead and select your choices. All right. We are going to close the poll. And so almost everybody voted for delay in starting systemic therapy. I can bring my cofaculty here back. But if you remember, when we first presented Steve, he had over 85% BSA. And I do not think any one of us would qualify that as moderate. I think even if the patient was not complaining of itch or wasn't saying they were bothered. I think we would all consider that severe.

And so, there is definitely an underappreciated severity for this case. And then a definitely a delay in starting systemic therapy. Do you guys want to make any comments on that?

Terry Faleye: I totally agree. When you talk about 85% BSA, I mean, that is truly significant. And even sometimes when you put that together saying, okay, how long it is taking this patient to even potentially be diagnosed and dealing with the disease. I think that definitely when you put it into context, this patient is likely miserable, probably not feeling the greatest. And so I totally agree. Underappreciated so far as severity, hands down. Definitely.

Victoria Garcia-Albea: Yes. And we listed in the case study he had ADHD, anxiety, depression, hypertension. All of these are comorbidities that are associated with atopic dermatitis. We do not really know how well controlled they are. But it is something to definitely ask about and make sure that they are hooked up with primary care and other avenues to deal with those.

All right. So Dr Lio is going to take us through some guidelines. We always love guidelines. He is going to help us go through some guidelines of how to approach patients with different severities.

[00:48:24]

          AAD Guideline Algorithm 2024

Dr Lio: So there have been some new guideline updates in just the past year or so, which is fantastic because the guidelines tend to be kind of behind the times. For a while they were like every 10 years. But I think now there is some real pressure to speed things up, because atopic dermatitis world is changing at a tremendous rate.

So when we think about, and this is focused on adults with atopic dermatitis, although I would argue much of it, at least in general, is applicable to pediatrics as well. But this is the American Academy of Dermatology guidelines.

And the first point, of course, is getting that baseline management. And that tends to be gentle bathing practices, good moisturization and avoiding the things that can irritate it. So allergens, irritants, certain types of fabrics, things like that. And then we also want to get a sense of the disease severity and the impact on quality of life and the comorbidity. That is really important. That is going to help us figure out where we are at and that is going to shape our treatment approach.

[00:49:25]

          Updates on Topical and Maintenance Treatment for Mild to Severe AD

And as we zoom down into the guidelines, as we think about through all ranges of severity, so mild to severe, we are really thinking about our topical approach first. And we tend to start there. And we are thinking about that in terms of both sort of a rescue approach and then a maintenance therapy. And this is relatively new concept I think, for those outside of the realm, new to atopic derm and eczema kind of groupings. But it is super important.

And it turns out it is cribbed directly from the asthma research, right? So asthma patients, if they get a lot of flares eventually it is like, okay, you need to be on something all the time to prevent flare-ups. But it turns out for atopic dermatitis, we have not done that. I would argue we have not done that routinely over the entirety of the country for a long time.

And we know we have a few different classes. So topical steroids. That is TCS. TCI is topical calcineurin inhibitors. We have crisaborole ointment which is a phosphodiesterase-4 inhibitor. We have ruxolitinib cream, topical JAK inhibitor. And we even have things like wet dressings, and most recently roflumilast which just got added to the list, got approved about a month or 2 ago. And that is another PDE for topical agent.

So that is the current landscape. And we can use these things to cool inflammation down, but also in a preventative way. And that is this idea of maintenance therapy. We can be reactive when they are flaring up. But then for those patients who need it we can have them applying. My preferred way to do it is a nonsteroidal agent. So I like to use a topical steroid when they are flaring and a nonsteroidal agent when they are better. But there has actually been studies using a lower potency steroid when they are better as a maintenance as well.

And certainly many of these treatments can also be used for a flare. Literally all of them can be used in that way as well.

So the idea here is we just want to make sure that we are using shared decision-making. We want the patient on board. We need good education. And we have to make sure if we are not getting good control, that we are thinking outside of the box. Are we sure that they are actually doing what we are saying? Are they getting the treatments? Are they actually applying them correctly?

I have had patients show me how much they put on. They put on like a little microscopic amount. And I am like, well, that is not going to be enough. You got a lot of eczema. Let me show you how to put it on. We have to think about alternative diagnoses. Do they have contact dermatitis? Do they have cutaneous T-cell lymphoma?

Yesterday, I had a patient with scabies infestation. So it is always a bit of a game if they are not responding. And of course then we can accelerate and move forward if we need to if they are not doing well with that. But it really does take that point where we stop to a timeout, make sure we are doing everything correctly before we think about our systemic therapies.

[00:51:52]

          Updates on Topical and Maintenance Treatment for Moderate to Severe AD

And something that is really been exciting in the last few years, before 2017, I would argue we did not have any FDA-approved systemic therapies for atopic dermatitis. So everything was off label. Everything was fairly dangerous. And we just tried not to go to systemic.

And I remember giving lectures where I was saying, like, I often feel like I am a failure when I have to go to systemic therapy for atopic dermatitis.

Well, now things have changed. So now I am beginning to see that my treat-to-target goal has gone up and up and up. Like I feel like I am able to get patients better than ever before. And my threshold for wanting to go to systemic has dropped lower and lower and lower. I am like you're using a fair amount of steroids. I am not that comfortable with it. I feel like you are not where I need you to be. Let us bring up the potential for systemics. And we have a bunch of things.

So of course, we have had phototherapy for a long time, which is really important but difficult for many patients to get a hold of. And then we have our biologic agents, dupilumab, tralokinumab. And just a week or 2 ago, lebrikizumab, which is really exciting. And those are all, I would argue, fairly similar. They are similar pathway.

Dupilumab is approved down to the lowest age, down to 6 months of age. Tralo and lebrio are down to age 12. And then we have our oral JAK inhibitors, upadacitinib and abrocitinib in the US. Baricitinib is not approved for atopic dermatitis in the US. It is approved for alopecia areata. But it is on here because in North America it is.

And then we have our older immunosuppressants, methotrexate, azathioprine, cyclosporin, mycophenolate. And systemic corticosteroids, steroids by mouth or by muscle, we really do not want to use. We really try to avoid them, and they are actually recommended against conditionally, which is important. Because I know a lot of good clinicians who will say, I still like these. I still think they are really helpful. I am going to still use steroids, and I really prefer not to use systemic corticosteroids whenever we can.

[00:53:41]

          Dupilumab Efficacy by Racial Subgroup: Wk 16

Now, when we look at some of these treatments in a little bit more detail, we know that dupilumab, obviously it has passed its test and is an FDA-approved medication. But when we look at the efficacy by racial subgroups, I think we see that this holds up. One of the interesting things when this first came out, it was, again, the first FDA-approved systemic agent. We thought, well, maybe it will help us split different subtypes of patients. Maybe we will see it work in a certain group. But it turns out it works pretty well across the groups, as you can see, which I think is very reassuring and actually makes our life simpler.

I mean, it would maybe be more interesting if there was a particular subtype, but it would actually complicate things more.

[00:54:18]

          Dupilumab Safety by Racial Subgroup: Wk 16

And again, this really also plays out, I think, pretty nicely in terms of the safety and tolerability. It is relatively consistent across the group. And there is some variability. But I think it is difficult because the numbers often are different. But I think by and large it is pretty similar.

[00:54:35]

          Lebrikizumab Efficacy by Racial Subgroup: Wk 16

Lebrikizumab as well, very similar efficacy by racial subgroup. It seems to perform quite nicely across the spectrum. And really I think what you are seeing the biggest changes here are the Q4 week vs the Q2 week, the lower dose of the Q4 week. And actually the way it is actually been approved is Q2 weeks to about 16 weeks. And if the patient is doing well, you can space out to Q4 weeks, which is nice. And you see that in those two middle pieces are very similar across groups.

[00:55:02]

          Lebrikizumab Safety by Racial Subgroup: Wk 16

And similarly with safety. I think safety and tolerability is quite similar across the groups as far as we can tell.

[00:55:10]

Abrocitinib Efficacy by Racial Subgroup and Skin Type: Wk 12

Abrocitinib, the oral JAK inhibitor. Again, very, very nice consistency across and I would not bore you too much. This is available for you to study closely if you wish. But I think the take home point is it is pretty consistent across the groups. Again, some of the numbers are smaller. So you might have a little bit more variability.

[00:55:28]

Abrocitinib Safety by Racial Subgroup and Skin Type: Wk 12

But I think again both efficacy and safety and tolerability very similar across the groups.

[00:55:33]

Upadacitinib: Efficacy by Racial Subgroup and Skin Type: Wk 12

And same with Upadacitinib. So we are kind of getting this consistent signal. And I think overall I am grateful for it because it really does mean that we can be inclusive. We do not have to be thinking, well, this particular group or even one day I hope we get to more personalized medicine where we can say for this particular patient, maybe they have a particular mutation or some epigenetic component that makes us want to change something for them. But I do not think we are quite there yet. So I think by and large, we can feel confident that we are going the right way.

So I am going to turn it back over to Terry to take us through some more questions.

[00:56:09]

          Posttest 2

Terry Faleye: All right. Thank you, Dr Lio. So we are going to go into posttest question number 2. And so it is, you would like to initiate dupilumab in an Asian patient with uncontrolled moderate atopic derm, but the patient is nervous about this switch. You share that subgroup analysis of clinical trials has revealed which of the following outcomes regarding efficacy and safety in patients with skin of color compared with White patient cohorts?

1. Lower efficacy and fewer adverse effects in patients with skin of color
2. Lower efficacy and more adverse effects in patients with skin of color
3. Similar efficacy and fewer adverse effects in patients with skin of color
4. Similar efficacy and more adverse effects in patients with skin of color

Go ahead and submit your answers in there.

[00:57:06]

          Posttest 2: Rationale

Okay, so the answer being C. Obviously similar efficacy and fewer adverse effects in patients with skin of color. And it looks like so far as the polling aspect, it looked like you guys were on par. But key thing is recognizing obviously the post-hoc analysis and 3 of the randomized controlled trials evaluating the efficacy and safety in regards to dupilumab across the racial subgroups. It showed overall, so far as efficacy across the groups and was observed while side effects occurred less in African Americans or even patients so far as in Asian population compared to those White cohorts. So definitely answered correctly.

[00:57:46]

          Patient-Directed Strategies to Address Disparities

All right. So when we are talking about just patient-directed strategies, and really for us addressing so far as those healthcare disparities, I think is really important, especially when we are talking about skin of color. But at the same time, just really talking about atopic dermatitis is recognizing that the things that obviously, there are always those barriers that have patients not come into the office or there is always that thing that kind of keeps them away.

But it is recognizing that there are obviously different things that could be definitely helpful. So whether it be expanded office hours to include night and weekends. I know that there are different offices across the board so far as in the derm spectrum that allow that and do that, obviously, to open up more avenues for patients to be able to have visits.

Obviously increasing so far as appointment flexibility. That way we are not having as many urgent care visits, obviously, or patients going into urgent care so far as for care where we know that we are dealing with something that has a chronicity effect so far as to it.

Telehealth visits, I think that was one thing that COVID brought to the forefront. But I think honestly, it has been amazing, especially for our patients that suffer so far as with atopic dermatitis or other conditions alike, because a lot of times those patients are not able to come into the office, if they are working, they got stuff going on, they got school, all those things. So I think it allows so far as a lot more flexibility.

And at the same time, obviously tailor education for varying needs and allowing so far as adequate time so far as within patient visit time and obviously access. Many times, we have those patients that come into office and we give them medication and we pray and hope they picked it up at the pharmacy. So it is recognizing finding ways to help these patients and to continuously have access. But I think in that obviously increases so far as the adherence to those things.

[00:59:22]

          Strategies to Address Systemic Contributions to Healthcare Disparities

So we know that there are definitely obviously systemic contributors that increase or add on so far as to the healthcare disparities that these patients alike that we have just talked about. I think number 1 is obviously increasing so far as education and awareness amongst our peers. I mean, sometimes it is interesting sometimes that patients may come in. And I mean, patients like Steve, that had all the significance so far as BSA involvement.

And sometimes you have these patients that suffer so much that are still getting just topicals. Sometimes it baffles us to like, but it is recognizing that the education and awareness is really educating our peers and knowing that there is a buffet and a range of options that are in our tool and our arsenal, and hopefully we are being able to utilize those options. It is no good if we have them and we are not totally investing it and utilizing in our patients.

At the same time, it is strengthening so far as those patient provider relationships. It is sad. And just like Tori talked about, those patients that it is a case where they have gone to office and to office and they feel like they are not getting so far as any help or they are not receiving the help that they need. I think communication, when patients feel like they are being heard, they are being listened to, I think is really important. And I think that all definitely helps.

And obviously increasing so far as representation. We all have those patients that have come into office. And I have had that when patients come in, they said, you know what, I looked you up because you are another person of skin of color. And I felt comfortable talking to you because I felt like you had skin that I had. And so I think sometimes is definitely obviously increasing our awareness so far as the disease and obviously recognizing the clinical presentation and variability.

But I think across the board, we should all be able to recognize these things, but as recognizing that we are treating each patient accordingly and just trying our best so far to do so.

[01:01:07]

          Shared Decision-making in AD

And then I think at the same time, it is really a shared decision-making. I know that many of us, we have to have patient buy in. I always say all the time it is a case where it is no good that if I put you on something and all of a sudden you come back in four weeks and I am just like, how are you doing? And they are just like, the same. And you are wondering have you been. But now just like Dr Lio said, are you putting on the cream. How are you putting it on? All those different things.

I think that sometimes when the patient walks out of the room, we really have to make sure, okay, are they bought in? So the treatment plan that I have definitely, obviously proposed, are they buying into what we are trying to do. And at the same time do they agree? Does it agree with their schedule? Does it not?

And I think at that moment we definitely are trying a customized treatment option for patients because we are meeting them where they are, obviously facilitating closer follow-ups. And at the same time, addressing patient goals. Recognizing cultural skin care practices is really big so far as in skin of color.

Many of times, if it is a case, if you tell a patient, wash with this shampoo 3 times a week, many times they are not probably going to do it. So I think that sometimes when we recognize that as providers, but at the same time we meet patients and they know that, you know what? That may not be up your alley, but let us come up with a plan that is going to at least mediate your disease process. But at the same time, we can be on a shared common goal. So I think that is really important as well.

So I am going to go ahead and turn it back over to Tori. And she will just go over more in regards to just the shared decision-making there.

[01:02:41]

          Resources to Facilitate Shared Decision-making

Victoria Garcia-Albea: Perfect. You bring up such good points about patient buy in, really asking how is this treatment going to fit into your life? Are you going to be able to do it? And it is hard. Sometimes you have to really push the patient to give you an honest answer because they want to say yes. They want to tell you they are going to do it. They probably want to do it. But then, if you think realistically, it may not be possible.

So you want to have certain components that really make patients feel welcomed. You want to have a conducive environment. You need to have good human resources. You want to have leadership support. Multidisciplinary clinics are the best way to do it, where you actually know the other people that you work with. Sometimes that is not always possible, depending on where you actually practice, but trying to make an effort to involve the nurses or medical assistants that you work with, being familiar with how much it is going to cost at the pharmacy, or little tips you can direct them to GoodRx or whatever it might be to help patients get access.

Internal training for clinical staff and the other healthcare providers that are involved. Using decision aids or worksheets that you can discuss with the patient. There are great websites out there. EczemaWise is an app that the National Eczema Association offers where patients can put in their symptoms and look stuff up about their condition.

So all of this is very helpful for patients to feel empowered and for them to come to the table where they can meet us and share in the decision-making process.

[01:04:19]

          Employing Motivational Interviewing

I mentioned this a little bit before, but we really need to engage with our patients. So building that trust. I like to try to sit down like if a patient comes in like our patient that we have been watching those videos and she has had it for 22 years and she just has not felt heard, sit down with the patient. This is the type of person who you really need to just take the time to listen to their point of view. You want to form an alliance, get them help to develop trust.

Asking permission is so valuable. Do you mind if I look at your back? Can I touch your hair? Is it okay if I move your hair around? Is it okay if you take your socks off or whatever it might be. Just acknowledging that it is a human being in front of you, and they may or may not feel comfortable with what you are about to do.

Focusing on what the patient finds most important. So like we have mentioned, their BSA or their body surface area may not correlate with what is the most bothersome to them. They may not show their groin. You have to go sort of probing and asking about are there other areas that are involved that are bothering you or other areas that you do not want me to look at, but that are involved that I can help you with?

Use patient-friendly language. Try to avoid using super technical terms if it is a patient that may not know those terms. Talking about whether there are advantages and disadvantages to not making a change. What is going to happen if we just keep doing what you have been doing?

And then asking patients for their ideas and solutions. What do you think is going to help? What can we do together to make your treatment plan more actionable.

Listening, of course. Like I said, sitting down, being eye to eye, give the patient time to answer, that 10-second like silent pause. Let there be silence, because the patient may be on the fence about speaking and bringing something up. And if you only wait 1 second, they may not be bold enough to share.

And then asking open-ended questions. I wanted to share this with you. I was watching Stranger Things with my kids the other day, and there is a scene where the guidance counselor is asking one of the, like, middle schoolers multiple questions about how they are doing because they have just been attacked by a bunch of monsters, and they are like, how are you? Like, are you doing okay? Is everything good or whatever? Like yes or no questions. And it was like supposed to be a terrible interview, but it was exactly what not to do.

So you just want to ask those open-ended questions. Again, give time for the patient to answer and think about the question like they do not know what we are about to ask. So give them time to think about it. And then make a plan that is collaborative, what do you want to do next? What is the most important thing to address? How can I support you?

[01:07:04]

          Crafting an Individualized Plan

All right. And then I think one of us mentioned, or maybe it was the patient mentioned that she did not know what she could do or what she should do. So this is just one example of an action plan for a patient with eczema. And I am sure you guys have all seen them. But on the left it is talking about what you can do instead of itching and scratching. So maybe applying a cool compress or doing something that is distracting.

The green zone is when their skin is looking good. So it is like how to maintain it. The yellow zone is when the symptoms are starting to flare up, but they are not at their worst. And then the red zone is when it is at its worst. And each section has instructions on what to do, what to take, when to apply it, what not to do, when to call the doctor and nurse practitioner or PA, etc. So this is something empowering that you can give to patients and you personalize it every time they come in, you adjust it depending on what you are prescribing.

[01:08:02]

          Patient Perspective

All right. So we are going to wrap it up by hearing some final thoughts from our patient about the impact of successful treatment on her atopic dermatitis.

Speaker: Having adequate therapies has definitely improved just my experience in managing the symptoms with atopic dermatitis. Just a couple of years ago, I was able to jump on a clinical trial that really supported me and my eczema. And I was so thankful to my doctor, who opened up that space for me to make me feel comfortable and confident, to even choose into a clinical trial and to move forward with a drug that, again, I did not know existed at that time.

And so the burden of living with atopic dermatitis has just definitely improved the patient outcome. For me personally it has definitely improved because I know my options, because I have done the research, because I have such great communication with my healthcare team now, where I am able to ask questions and communicate what I am going through with them. And it is almost like we are co-creating together.

Terry Faleye: That is awesome.

Victoria Garcia-Albea: So great. Yes, it is so nice to end on a happy note, but this is just one case. And unfortunately, there are plenty of people who have not been able to reach that level of satisfaction with their care.

[01:09:30]

          Faculty Insights and Key Takeaways

So we covered multiple things tonight and we hope that you took some key points away.

• So we talked about variable presentation and severity and atopic dermatitis
• We talked about an individualized approach is key for improving patient and disease related outcomes, which you just heard was so valuable for that patient
• Systemic therapies have demonstrated efficacy and tolerability across racial and ethnic subgroups and should be incorporated into treatment plans when indicated. You have those guidelines to fall back on to help you know when it is appropriate to use systemic therapies
• We talked about engaging patients in shared decision-making and how that is really necessary to improve their self-management, their adherence to their treatment, and their overall quality of life
• We talked about developing patient-specific plans that address barriers to care and atopic dermatitis, which will then optimize their outcomes
• We talked about addressing disparities of care
• We really hope that you learned that an integrative process at the practice and policy level to help address healthcare disparities is just super important

And so submit your questions if you have any. We have one in the chat. We are going to get to that one in a minute.

[01:10:45]

          Posttest 3

We have a posttest question which is more open-ended. How often do you plan to consider strategies to address disparities when designing a treatment plan for moderate to severe atopic dermatitis? So this one you only can choose one answer.

1. Never
2. Rarely
3. Sometimes
4. Frequently
5. Always
6. Not applicable

So go ahead and select your answer now.

All right. We are going to close that poll. Most people said always. Very good.

Q&A

Victoria Garcia-Albea: All right. And so we are going to go over questions and answers. So we do have one question in the chat. And feel free to continue to submit. What is the difference between urticaria and atopic dermatitis? Do Terry or Dr Lio, you want to take that one or do you want me to?

Terry Faleye: You can go ahead and you are already on a roll.

Victoria Garcia-Albea: All right, feel free to chime in. They are totally different. So they look different. They are caused by different etiologies. If the person who wrote the question wants to, like, elaborate at all on what is confusing. I am happy to have a little chat. But urticaria is more of a dermal process. So it is when there is edema in the skin. So there is like swelling in the skin. It is usually an allergic reaction and it is super itchy. So that overlaps with atopic dermatitis. But you are not going to see that lichenification or scale that you see in atopic dermatitis.

Another difference is atopic dermatitis tends to be symmetric. I always say in dermatology we are all about patterns. So AD, as Terry covered that slide on like the presentations of how it looks in different ages. It really is pretty consistent with different ages, but usually symmetric. Urticaria can be all over the place really like random. And we do not treat urticaria usually with topical steroids because the lesions tend to move around, whereas we do with atopic dermatitis. You can treat both with antihistamines, but they really are pretty separate conditions.

Anything you guys want to add?

Terry Faleye: No, good deal.

Dr Lio: Yes. And just to remember that they are really different components of the immune system. So there is this huge issue with people doing testing for allergies looking to fix their atopic dermatitis but they are doing prick testing which looks for urticaria or responses. And we know that while it is possible that, let us say you are allergic to grass and the grass gets on your skin and you get hives, I guess that could trigger an eczema flare. But that is not eczema, right? That is different.

So there is often this conflation and confusion. People say, well, they told me I am allergic to these things. And the same goes for foods. If you are allergic to peanut, right, you do a prick test or a blood test looking at the IgE specifically to peanut. Well, that means you are going to have a high reaction and maybe a severe high reaction like angioedema or even anaphylaxis peanut. But we know our peanut allergic patients, they are not cheating. They are not sneaking peanuts in, right? And they still have terrible eczema.

So in fact, what we really understand, at least for a component or a subgroup of these patients, is that the way they become allergic, okay, is through their skin, transcutaneous sensitization. So allergens, particularly food allergens, get through the broken skin barrier. Then they become sensitized to them getting specific IgEs to these things. So they have both eczema which then allows them to develop urticaria. That is specific to things. And they are often confused, even sometimes by allergy colleagues.

Sometimes we will be talking like wait a minute, these are different arms of the immune system, T-cell mediated predominantly. And the other one is IgE and mast cell with histamine, right?

Terry Faleye: Yes. That is good. I mean, and just to your point, Dr Lio, many a times, in case you have those patients that come in and they have AD and they have eliminated everything from their diet, and they are just like, okay, I need to stop this, this. I got dairy, I got this. And at one point you are almost wondering if they are eating. So it is a case where it is just really just recognizing that we are definitely so far as dealing with 2 different total disease processes.

And many times patients will think that, okay, I automatically need to see an allergist for this. Not to say there is not going to be overlap, but at the same time it is it is definitely obviously not the norm.