Closing Thoughts With Patient Cases: Choosing the Right Topical Treatment for Patients With Atopic Dermatitis
Panelists discuss how choosing topical treatments requires individualized therapy considering factors such as affected body areas, disease severity, patient age, formulation preferences, and insurance coverage.
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Clinical Decision-Making for Topical Treatments in Atopic Dermatitis
Overview
This discussion highlights the nuanced and individualized approach necessary for the selection and management of topical treatments in patients with atopic dermatitis. The emphasis is on patient-centered care, incorporating factors such as disease severity, anatomical site, patient age, treatment history, patient preferences, and insurance coverage. Proper follow-up and patient education are also underscored as key components to ensuring efficacy and safety.
Topical Treatment Selection: Key Considerations
Patient-Centered, Individualized Approach
- Holistic assessment is essential, taking into account not only the clinical presentation but also patient lifestyle, age, preferences, and accessibility to medications
- Formulation preferences (eg, cream vs ointment) should be considered to promote adherence
- Insurance and cost factors may influence medication choice and availability
Disease Severity and Location
- Mild to moderate disease, or involvement of sensitive areas such as the face, neck, or intertriginous zones, warrants the use of low-potency topical steroids (eg, hydrocortisone 2.5% or desonide) or nonsteroidal options (eg, tacrolimus, roflumilast, ruxolitinib)
- Moderate to severe cases or involvement of thicker skin areas (eg, hands, trunk) may require medium- to high-potency topical steroids (eg, triamcinolone, clobetasol, halobetasol)
- For chronic management, nonsteroidal agents may be used after initial steroid therapy, particularly in steroid-sensitive areas
Age Considerations
- Pediatric and young adult patients may require more cautious use of steroids, with a preference for nonsteroidal agents, especially in long-term treatment plans
Duration and Safety
- Topical steroids should be used for limited durations to avoid adverse effects such as skin atrophy and striae, especially with chronic use without breaks
Improving Adherence and Treatment Outcomes
Follow-Up
- Regular follow-up (typically every 6–8 weeks) is critical to:
- Monitor response
- Assess for adverse effects
- Ensure correct medication usage
- Provide ongoing education and address barriers
Education and Communication
- Use clear and specific written instructions (eg, smart phrases or after-visit summaries)
- Provide visual aids or demonstrations, when possible, to enhance patient understanding
- Discuss realistic expectations regarding efficacy and safety of each treatment
Empowering Patients
- Encourage self-management strategies including:
- Use of eczema-safe products (refer to National Eczema Association resources)
- Lifestyle modifications: avoiding hot showers, using fragrance-free products, following gentle skin care practices
Criteria for Referral to a Dermatologist
Referral to a specialist is recommended in the following scenarios:
- Inadequate response to first-line therapies
- Chronic, relapsing, or severe disease affecting quality of life
- Need for systemic therapy, biologics, or light therapy
- Presence of secondary infections (viral or bacterial)
Case-Based Learning Points
Case 1:
- A 30-year-old woman with facial atopic dermatitis unresponsive to topical hydrocortisone
- Recommendation: Nonsteroidal topical agent (eg, tacrolimus or ruxolitinib) due to facial sensitivity and inadequate steroid response
Case 2:
- A 16-year-old boy with long-term, uninterrupted use of triamcinolone leading to significant striae
- Lesson: Avoid prolonged topical steroid use without medical supervision. Highlight importance of scheduled treatment breaks and monitoring
Final Takeaways
- Optimize topical therapy through individualized regimens tailored to patient and disease factors
- Educate and follow up consistently to enhance adherence and safety
- Use nonsteroidal agents appropriately, especially in steroid-sensitive areas and for chronic use
- Recognize when to escalate care or refer to dermatology for systemic intervention
- Support patients with reputable resources like the National Eczema Association to aid in self-care and product selection
