Treatments for atopic dermatitis

We have fantastic treatments now for atopic dermatitis. We don't want our patients out there suffering, getting infections, getting the complications.

[Music] Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed, and free.

Atopic dermatitis is a common problem in childhood and for some adults. You probably know of it as eczema. It's an itchy rash that can range from mildly annoying to severely impacting people's lives. Treating atopic dermatitis is important. It's not just about quality of life. Adequate treatment prevents complications that can result from chronic itching, acute problems such as skin breakdown and infection, and then over time thickening of the skin.

I'm Dr Laura Beaton, and I'm your host for this episode. As a GP, I do see and treat a lot of atopic dermatitis. And today on the Australian Prescriber Podcast, it's my absolute pleasure to speak with an expert. Associate Professor Gayle Ross is a Dermatologist and Lead clinician at Royal Melbourne Hospital's Atopic Dermatitis Clinic. Gayle's written a great article in Australian Prescriber, which goes through the drug and nondrug treatments for this really common condition.

Thank you so much, Gayle, for the article, and welcome to the program today.

Thanks for having me.

You're very welcome. To start with today, Gayle, I want to ask you, how important are the nondrug treatments for atopic dermatitis? Without them, would the medicines ever be enough?

We do see that the nondrug treatments are really the foundation or the cornerstone of treating atopic dermatitis. Without them, even with the great new treatments that we have available, we would see that those treatments may not be so effective. So basics, including avoiding triggers, keeping cool, keeping well-moisturised, avoiding soaps and any specific allergies, do remain really important and we focus on those at the start of our treatment with every patient.

It's amazing how often, even though they might've had their condition for decades, how many of them are getting it wrong. And it actually explains quite a lot why they're not doing as well as they could be.

And one of the things I loved in your article was you list the difference between skin irritants separately to the idea of an allergy, and I thought that was really helpful. Can you talk us through how you see the difference of these two for atopic dermatitis and maybe even how you explain it to patients?

Sure. So, I see irritants as something that would cause problems for all of us. Any one of us who washes our hands 20 times a day with soap is going to end up with hand dermatitis. It'll just take the atopics less time and less washing than it would take people with normal skin. So, irritants like exfoliating, for example, that's highly irritating to everybody's skin if you're too rough, that friction component. I'll explain to patients that they should try and be gentle to their skin and just avoid anything harsh that's going to cause their skin barrier to break down.

Allergens are quite separate. Most atopics have a higher tendency to allergy wired into their overactive immune system. Not all patients will have allergies, but we certainly look out for them. And we think about allergies, for example, when there's a pattern of dermatitis, particularly on the face. You're going to be more suspicious that they might have, for example, contact allergies to cosmetics or to airborne factors like house dust mite or pollens and grasses.

I guess one of the things that I really got from your article as well is that focusing on the triggers, which as you said is important for actually everyone's skin health, you're probably going to get more bang for your buck than hunting for one particular allergen for most cases of atopic dermatitis.

Yeah. I say to patients it's 90% heat and dry skin and common everyday irritants, and 10% might be all these other things that we can go hunting really hard for, but we may not find, or we may not find anything that makes a huge difference to their actual severity.

Great. And in the nondrug treatments, it sounds like moisturiser is again the cornerstone here. And so if you don't mind, let's talk a little bit about moisturisers. The moisturising industry probably doesn't like what I'm going to say, but your message is pretty clear. Bland and inexpensive moisturisers are acceptable.

‘Any moisturiser is better than no moisturiser,’ is what I tell the patient. So, if cost is a factor, it doesn't have to be anything fancy. To be honest, a lot of the expensive ones, they tend to contain a whole lot of unnecessary ingredients that might smell nice, look nice, and are very appealing but won't actually be ideal. I always worry when patients say it's ‘organic’ or ‘natural’, because that generally means it's got essential oils or plant extracts that may well be sources of allergy for these patients.

What I do like though, are what we call the ceramide moisturisers. These are the next generation moisturisers, which may be slightly more effective, sort of replacing what the patient's genetically lacking in their skin barrier.

And ceramide moisturisers, are they very expensive? Is this something that is in the reach for most patients with atopic dermatitis?

I'd say most patients can afford it. A big tub of a simple ceramide moisturiser would be maybe $20 or $30. So yes, it's not $5 or $6 like a sorbolene or a Dermeze, but it's not exorbitant.

And I think when it comes to really maintaining skin health, the more time and money you can put into that, the less often you'll have to attend doctors for flare treatment for your atopic dermatitis. That's a good message to give.

And look, this is maybe a question that comes across in clinic and when I read the article, but with moisturisers, do you think it's volume? Is it frequency? What's the most important thing when telling people about moisturisers?

I would say frequency. I try and encourage my patients to moisturise twice a day, particularly when they're having a flare or the more the better. The ones who only moisturise infrequently, they just can't keep that dryness under control. Even if it's once a day, that's going to be helpful. And again, the ceramide moisturisers might last a little bit longer on the skin so they don't have to moisturise quite as often, which also makes it more cost-effective.

Great. Well, let's move on to some of the medical treatments. And, of course, topical corticosteroids are the most important treatment for atopic dermatitis. Could you talk us through how you pick which steroid to use, for where, and how potent it should be, and what you've taken to mind when thinking about the formulation or delivery vehicle?

Yeah, absolutely. Obviously, very important and we need to encourage our patients to not avoid these and to not use them sparingly and that if they use the correct strength for the site, they won't have any side effects. This is always how I preface it to the patient, because there's so much steroid phobia out there.

I go in terms of site. So for the face, the only steroid I'm happy to use is 1% hydrocortisone. And because that's pretty mild and may not be very effective, I say to the patient, ’If you've used this for two weeks, and it really hasn't done much, you need a calcineurin inhibitor.’ And then, I'll offer either pimecrolimus or tacrolimus. Tacrolimus is my favourite, because it's more effective but again, a little bit more expensive, but we can compound that as either a cream or an ointment, so it gives the patient the option.

Pimecrolimus—still very, very helpful, but the quantity is quite small and being a cream, it might not be quite as moisturising. But that's how I deal with the face, and again, giving patients the option there, just say these are all safe twice a day. Don't stop until you're clear. There's no time limit and then, you can still use it twice a week as maintenance on areas that you know are prone to flaring up; for example, the eyelids.

For the body, anywhere from the neck down, my standard strength would be methylprednisolone aceponate, so Advantan or mometasone furoate so your Elocon, Novasone, Zatamil. I see those as fairly equivalent in strength. I don't go weaker than that, because they don't tend to work. The bigger tubes I know are very convenient, but they take a lot longer to work, and the patient generally gives up before their skin has cleared. I see it as being a little bit weak to be effective and still too strong for the face so I'd rather just give them an authority prescription for lots of tubes of our mid-potency topical steroids.

And then, for feet and hands, being very thick, tough skin, we need to go stronger. My favourites there would be betamethasone dipropionate, Eleuphrat or Diprosone, and again, patients can go straight to that. They don't have to start weaker and build up. I want to get them under control quickly so that they don't feel this burden of needing to use the topical steroids all the time. I say at the first sign of a flare, get onto it and don't stop until your skin is clear, however long that may take. I don't like giving them a time limit to say, ‘You can only use this for five days or seven days,’ because inevitably that induces some fear. And when they stop at five days and they're not clear, they're going to be really disappointed. It's going to be still grumbling on, and you're just never going to win.

Thanks for that. That actually went through the next couple of questions I was going to ask you. But it's really interesting to hear you say that really we shouldn't be telling people there's a strict time limit on these steroids, because we might actually be reinforcing some fear around using topical steroids.

I think so. This is where I say if you are using the right strength, you can't go wrong. We just don't see side effects from the topical steroids that I've mentioned in those sites. The commonest side effect we would see would be if a patient uses one of the middle-high potency topical steroids on their face. They'll get periorificial dermatitis. We see that all the time.

So do I.

That's the reason I don't like them. And then, the other concerns about cataracts and glaucoma if they use them on the eyelids. If they just get very strict rules about ‘this is what you use for each site’, and they need a plan where this is written down so I give them an information sheet where it actually specifies face, body, hands and feet, scalp, because they'll need a lotion if they have scalp involvement rather than a cream or ointment.

I think until I started becoming a prescriber, I hadn't realised all the different vehicles, lotion versus cream versus ointment.

And this is again something that's relatively flexible, and I'm happy to work with the patient and their preferences. There are patients who hate the greasy texture, and they just won't use it. I'd rather give them cream in that instance, even though I know that the ointment is more moisturising, there's fewer preservatives in an ointment, so they don't have as many reactions.

But as I said, I'd rather they use it and they like the feel of it than just never fill that prescription or just not use it. And again, some issues specific to the site; an adolescent with a tendency to acne – I would never give them an ointment for their face, it's just going to exacerbate the acne. All this thing about hairy areas, I think it's more about ease of application. Sometimes we see folliculitis with ointments, and it's better to go for the lighter vehicles. And sometimes they'll have a preference based on stinging as well. Some of the vehicles on broken, open skin will have more of a stinging effect than others.

In your article, you also go through the adjunct treatments that we provide, like bleach baths or wet dressings. When are the times that you recommend adjunct treatments on top of the correct steroid for the correct site?

If the patient has a lot of weeping, scabbing or crusting, I'm worried about infection, and I will encourage them to do bleach baths in conjunction with their topical steroids. Bleach baths have really changed the landscape dramatically, so we almost never use antibiotics for infected eczema nowadays unless the patient's quite unwell.

Patients who haven't done it before, it sounds a little bit scary, but I say it's like swimming in a swimming pool, only for shorter periods of time. If the patient is in bleach for too long, it can be a bit drying, so that's why my preferred way of doing it is with a bit of bath oil and any kind of salt. This can be table salt, sea salt, Epsom salts, pool salt, a nice generous cup or two plus a nice slug of bath oil. And at the last 2 to 5 minutes of the bath I get them to add in the plain fragrance-free White King and sit in it 2 to 5 minutes, hop out, pat dry, and that's a bleach bath.

Great. And it's working to try to reduce the staph load on the skin?

Reducing staph colonisation. So staph is a massive issue for atopic dermatitis and a big cause of these patients flaring. We not only need to keep the levels down but treat it if they're having a flare. Bleach baths is a really common adjunct. And then, antihistamines, while they might not be fantastic on their own, they do play a role, and I encourage patients to take them regularly, because they are very safe and can lower the itch a little bit. But they do need to be taken regularly and sometimes at higher doses than it says on the pack. So again, I need to reassure the patients that that's safe to do, barring, of course, the under-two age group where we're a little bit more concerned about antihistamines, just with the risk of SIDS. But I think most people wouldn't be necessarily needing to give antihistamines to the infants.

Yes. And look, itch is such an annoying symptom for patients. They're often desperate for anything that's going to help. And often, it's all of the above.

Yes. You throw everything you have at it. That's exactly right. And often, if they're not sleeping, get them to use a sedating antihistamine. That's also when the wet wraps come in. Wet dressings, it can be wet pyjamas, it can be wet tubular bandages or the traditional soaked Chux cloths held in place with crepe bandages. Whatever works for the patients overnight can be helpful to give them a better night's sleep or just for a few hours here and there.

In your article, you do mention that most of atopic dermatitis is managed in general practice with the measures that we've gone through today. But then, some people do need specialist care, and there are lots of second-line treatments available. Would you mind talking through what happens when they might come to you at Royal Melbourne's Atopic Dermatitis Clinic?

A lot of patients who come and see us, they've had eczema for a really long time. And unfortunately, a lot of them have not been offered a specialist appointment for a long time as well. They've had really poor quality of life, and they've just been on the merry-go-round of, here, have some more topical steroids or, here, have a course of prednisolone when they've come in for a flare, without actually being aware that there's anything else available.

I think it's really important for the GPs out there to say to these patients, ’If you're struggling, let me know, and there is more that can be done.’ It's not all scary to move on from topical steroids, and I think it's very helpful.

The sorts of options that we would give the patients depends a little bit on their severity. In that moderate category, or mild but just needing more than the topicals alone, then phototherapy can be fantastic. Patients really like it because it's a nonpharmacological therapy and it's often quite effective. It's just fairly inconvenient and obviously takes time to work, so we encourage patients to attend usually 2 or 3 times a week for about 6 weeks. That can be done in public hospitals or through a dermatologist.

And then, we've got our traditional immunosuppressants that are also still used in that moderate category. We quite like methotrexate. It's not terribly immunosuppressive. A short burst of cyclosporin can be useful, or potentially even azathioprine is used quite a lot in the paediatric age group, and mycophenolate as well. These are all agents that have a role still in patients who are not eligible for advanced therapies.

And in general practice, I think that's a great message for us to hear as well. Refer on when needed and refer early, because there's quite a long wait list often to see a specialist dermatologist. But knowing that we can work on all of the other measures and really optimising those while someone's awaiting their specialist appointment.

But also keep in mind if you have a friendly local dermatologist, call them. Say, ’I've got a patient. They're having trouble. They're really bad.’ I personally, and I'm sure a lot of my colleagues would say, ’Sure, we'll squeeze them in.’ This is why we're here. We have fantastic treatments now for atopic dermatitis. We don't want our patients out there suffering, getting infections, getting the complications. We're more than happy to see them if they're having a problem.

Gayle, what are the advanced treatments that are available for atopic dermatitis?

We have two advanced treatments now available on the PBS for severe atopic dermatitis. To be eligible for advanced treatment, our severe patients only have to have failed 4 weeks of topical steroids. So, they don't have to have done any other systemic treatments to be eligible. They just need to be in the severe category.

And the two treatments, we have a dupilumab, which is an interleukin-4 and -13 blocker, and upadacitinib, which is a JAK inhibitor. So quite different agents. The monoclonal antibody dupilumab, that's a subcutaneous injection fortnightly, available for patients over the age of 12, although it is TGA-approved for 6+, and we’re still hoping to get it on the PBS in the not-too-distant future. All designed for long-term use, so patients who have severe atopic dermatitis, it's not necessarily going to ever get better by itself. They need an effective safe treatment that they can stay on long term, and it just removes all of those flares, takes away the itch very quickly, and very, very few side effects. Dupilumab is very much second line after topical steroids in a severe patient.

Upadacitinib is another very useful agent as a tablet. It is considered slightly immunosuppressive but probably less immunosuppressive than our traditional agents like cyclosporin and it's again designed for long-term use. A similar patient population but, being a JAK inhibitor, there's blood-test monitoring required, and we need to select our patients carefully to minimise the potential side effects. There are some concerns around thromboembolism, for example, and cardiovascular disease, elevated lipids in patients on JAK inhibitors, which we ask our GP colleagues to help in monitoring and managing.

And also managing their optimal vaccination, and then making sure we're not giving anyone any live vaccines while they're being treated.

Yes, we encourage our patients to be vaccinated, particularly against shingles. The JAK inhibitors do have an increased risk of shingles. And now that the Shingrix vaccine is coming on the PBS for immunosuppressed patients, this will remove a lot of the cost burden, which is great. We also like it because you don't have to interrupt treatment or delay treatment, unlike the old live vaccines.

Now, Gayle, unfortunately it's all the time we've got for this episode. And for all of you listening, I do recommend that you read the full article, which is on the Australian Prescriber website. Gayle, thank you so much for your time this afternoon.

Absolute pleasure. Thanks for having me.

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I'm Laura Beaton. Thank you for joining us on the Australian Prescriber Podcast. The views of the hosts and the guests on this podcast are their own and may not represent Australian Prescriber or Therapeutic guidelines. Gayle Ross has been a paid speaker, and on medical advisory boards for AbbVie, Leo Pharma, Sanofi Genzyme, Lilly, Johnson & Johnson, and Ego Pharmaceuticals.