EXPERT ANALYSIS FROM THE CARIBBEAN DERMATOLOGY SYMPOSIUM
The future looks bright for new atopic dermatitis treatments, according to Dr. Charles Ellis, a dermatology professor at the University of Michigan in Ann Arbor.
“I think we are at the point where we were with psoriasis some years ago; if you think back 15 years, we had methotrexate and that was about it” systemically for psoriasis, but then the biologics arrived. “We are at that point now” for atopic dermatitis, with biologics in the pipeline. “I think we’ve turned the corner,” Dr. Ellis said at the meeting sponsored by Global Academy for Medical Education.
It “should make a big difference for patients; there’s an unmet need for systemic treatments. The leading candidate is dupilumab; the data look good,” he said.
Trials of the human monoclonal antibody report that over 80% of patients achieve 50% reductions in Eczema Area and Severity Index scores, versus about a third with placebo (N. Engl. J. Med. 2014;371:130-9). Dupilumab is currently in phase III testing.
A Food and Drug Administration advisory panel recently and unanimously recommended approval of another human monoclonal antibody, secukinumab, for plaque psoriasis. “It could be useful in atopic dermatitis. It’s certainly something that we want to look into,” Dr. Ellis said.
Both agents are interleukin blockers, and more are in development, along with drugs and biologics with different targets.
Meanwhile, the phosphodiesterase inhibitor apremilast , approved by the FDA in 2014 for plaque psoriasis and psoriatic arthritis, is being studied for atopic dermatitis, although results aren’t due until 2016.
Overall, and at least with current treatments, “I think the main thing that we do” at the University of Michigan “is treat aggressively. When you treat aggressively, you show patients that the therapy works, so they are much more likely to use it,” Dr. Ellis said.
One-percent hydrocortisone cream is the strongest thing that a lot of patients have tried by the time they walk through the doors in Ann Arbor; many are close to losing hope in medical treatment.
Because of that, “we are more likely to use higher-potency topical corticosteroids, and use them more often and under occlusion. We are very likely to try triamcinolone in children and sometimes even more potent corticosteroids in adults. We [also] use a fair amount of methotrexate.” The heightened approach can “make a big difference,” he said.
Customer service is another focus at the university. If patients or parents feel better about their visits – not just with the doctor, but from their appointment phone calls right through to their checkouts – they are more likely to stick with treatments.
Dr. Ellis leads a service excellence program to train physicians, nurses, and ancillary staff to ensure that visits go well and patient needs are met. It’s “similar to what you might find in a fancy hotel chain,” and has proven itself with high patient satisfaction scores, he said.
A thorough history is part of good customer service. One thing to pay attention to is calcium channel blocker and thiazide use in older patients.
Both can cause chronic eczematous eruptions that look like atopic dermatitis, and elderly people might have been on the drugs for so long that the relationship with skin problems is easy to miss.
“If you haven’t contemplated particularly calcium channel blockers as a potential cause, you might not give patients a chance to go off them for a while to see if it helps,” he said.
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Dr. Ellis is a consultant for Celgene, Ferndale, Otsuka, and Johnson & Johnson.