Proceedings of the Fifth SKIN SPECTRUM SUMMIT

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Optimizing topical therapy in AD
Dr. Maha Dutil
Topical treatment of atopic dermatitis (AD) involves
a multi-angle approach for both managing
flares and ongoing maintenance, but there
are both well-established therapies and new agents
for this condition that can produce improvement.
That was one message Dr. Maha Dutil included in her
presentation on AD at Skin Spectrum Summit in
Toronto.
The basis of any care regimen is emollient use, Dr.
Dutil said, noting that studies have shown that moisturizing
alone can improve the eczema score. Bathing habits,
too, are a non-medical factor that can impact AD symptoms,
she said, recommending that patients with AD only
bathe once every two to three days to reduce the drying
effect.
Topical treatments for AD include topical steroids,
topical calcineurin inhibitors (CNIs) and PDE4 inhibitors.
Steroid phobia is common even though, when used
properly, steroids are very valuable, she said.
“If you counsel the patient and use low- to mediumpotency
steroids, you do not really have many side effects,”
Dr. Dutil said. “There is a long history of safety
when used correctly, and they are very effective at cooling
inflammation down quickly. They relieve the itch, and
they are inexpensive.”
She recommends prescribing low-potency steroids
for the face and folds and mid-potency steroids for the
body, arms and legs. “I leave the high-potency [steroids]
… for the palms and soles.”
For patients who do not respond to a topical steroid,
have developed a side-effect or an intolerance or have
become dependent due to overuse, Dr. Dutil says switching
to a topical CNI or a PDE inhibitor could be a good
choice.
Topical steroids should also be avoided in adolescents
or preadolescents. “If you happen to hit them during
their growth spurt with a topical steroid, you increase
12 • Proceedings of 2019 SKIN SPECTRUM SUMMIT
the risk of sideeffects,”
she said.
CNIs “suppress
inflammation
by inhibiting
calcineurin-dependent
T-cell activation.
They are
anti-inflammatory
without being antiproliferative.
They improve
skin barrier function,
and they reduce
Staph.
carriage.” With these products, patients should be counselled
that approximately 20% of patients experience a
transient burning sensation on application, lasting
roughly 10 minutes, for the first few days of treatment. Although
there is a safety warning in the monographs of
these products, Dr. Dutil noted that in 20 years of clinical
experience with topical CNIs, no link has been found between
use of these products and skin cancers or lymphomas.
The newest option is PDE4 inhibitors, one of which,
crisaborole, was approved in Canada in late 2018. “Phosphodiesterase
degrades cyclic AMP and is overactive in
patients with atopic dermatitis. So by decreasing phosphodiesterase,
cyclic AMP goes up in the cell, and it reduces
inflammation,” said Dr. Dutil.
She mentioned a four-week study of PDE4 inhibitor
treatment in patients aged 2 and older with mild-to-moderate
AD. In that study, by day 29, a third of patients were
clear or almost clear, with a two-grade improvement. “It
helps the itch within a week. It is probably because cyclic
AMP goes up in all the cells, not just the skin cells. It also
goes up in nerve cells. That may be an effect.”
Steroid sparing and
Dr. Katie Beleznay
Individuals with very dark skin
may be at elevated risk of developing
atopic dermatitis
(AD). That, combined with the
chronic nature of AD and the tendency
for darker skin to develop
difficult-to-treat post-inflammatory
pigment changes, suggests
that encouraging treatment adherence
and reducing the frequency
and severity of AD flares
are particularly important in this
population.
This was a point brought up by
Dr. Katie Beleznay in a talk at Skin
Spectrum Summit in Vancouver.
Dr. Beleznay said that on presentation
many patients expect she
will be able to cure their eczema.
“And I say, This is a chronic condition,
similar to high blood pressure
or diabetes,’” she said. “Some conditions,
some people get them despite
everything you do. What we are
going to do is try to help you manage
it better.”
She said she often illustrates the
cycle of AD to patients by drawing a
sinusoidal curve, explaining that the
peaks of the curve represent AD
flares. She tells patients, “Our goals
with treatment [are] to reduce the
peaks—the severity of the flares—
and … increase the time between
the flares.”
The cornerstone of any treat-