Management Optimization in Atopic Dermatitis - Episode 1

Persistent and Recurrent Atopic Dermatitis

Peter L. Salgo, MD: Hello, and thank you for joining this American Journal of Managed Care® and Specialty Pharmacy Times® Peer Exchange® video program on atopic dermatitis. Current treatments for atopic dermatitis are often topical and revolve around symptom management, while emerging therapies represent a potential paradigm shift, in terms of providing disease control, and will likely require specialty pharmacy involvement to optimize management and control costs. Today’s panel of experts on this Peer Exchange® will provide an overview of the clinical and economic burden of atopic dermatitis, and they’re going to highlight emerging therapies. The panelists will also provide insight on ways that health plans and specialty pharmacies can prepare as these new treatments are entering the market.

My name is Dr. Peter Salgo, and I am a professor of medicine and anesthesiology at the College of Physicians and Surgeons at Columbia University and associate director of surgical intensive care at the New York-Presbyterian Hospital. Joining me on this distinguished panel are: Cheryl Allen, vice president of industry relations at Diplomat Specialty Pharmacy; Dr. Jeffrey Dunn, senior vice president and chief clinical officer at VRx Pharmacy Services; Dr. Ed Pezalla, most recently at Aetna as the vice president for pharmacy policy and strategy; and Dr. Jonathan Silverberg, director of Northwestern Medicine Multidisciplinary Eczema Center and assistant professor of dermatology at Northwestern University Feinberg School of Medicine.

Thank you all, again, for joining us. Why don’t we begin with the basics here? Jonathan, help us out. Set the stage. What is atopic dermatitis? How common is it?

Jonathan Silverberg, MD, PhD, MPH: Atopic dermatitis is a fairly common chronic inflammatory skin disorder. Its hallmark is really this itchy rash that occurs, and it’s a fairly common disorder, certainly in childhood. It may affect up to 20% of children depending on the state.

Peter L. Salgo, MD: I just want to stop you. Any disease that affects 20% of anybody is a real problem, no?

Jonathan Silverberg, MD, PhD, MPH: Absolutely. The majority of those cases are going to be fairly mild. From the evidence out there, we know that about two-thirds will be mild, maybe about 25% moderate, and 6%, 7% severe. And it’s not always severe throughout their entire life, but it’s something that can really be a major burden for them.

Peter L. Salgo, MD: Well, walk me through this. How does it present? What does it look like?

Jonathan Silverberg, MD, PhD, MPH: There’s an age distribution where it may vary very much by age. In infants, there’s more of a facial or a head and neck dermatitis. There’s a lot more oozing—almost like a blistering phenomenon—weeping skin. It’s very, very discomforting for children; intense scratching.

Peter L. Salgo, MD: It sounds like it hurts, actually.

Jonathan Silverberg, MD, PhD, MPH: Absolutely. And you can get both the intense itch, as well as intense pain that goes along with it.

Peter L. Salgo, MD: So, that’s how it presents in infants. If it occurs later in life, what does it look like?

Jonathan Silverberg, MD, PhD, MPH: When you move into the toddler years, you tend to get more of the so-called extensor distribution, where it tends to affect more of this part of the arms and legs. And we think part of that is from friction, crawling, and just kids getting into everything. But the hallmark pattern that we look for, really throughout later childhood and adulthood, is the so-called flexural eczema, where it affects the creases of the elbows, back of the knees, front of the neck, wrists, and ankles. And those are really that pathognomonic distribution that we look for when we’re trying to make that diagnosis.

Peter L. Salgo, MD: Again, if it’s in these flexion areas, that can’t be comfortable. It’s got to be awful.

Jonathan Silverberg, MD, PhD, MPH: Absolutely not. It’s something that the skin will often get very thick from chronic rubbing. There will be deep gouges in the skin from scratching. There’s often a lot of bleeding onto the clothing and on the sheets. The intense itch and pain really just takes over and consumes every part of patients’ lives.

Peter L. Salgo, MD: I understand it comes in various flavors, too. There’s acute, subacute, chronic. How does that present? Who gets what?

Jonathan Silverberg, MD, PhD, MPH: The acute form is typically more common in childhood, where they get that weeping, oozing skin. Subacute really can happen at all stages, from early childhood all the way into adulthood. And in those cases, it tends to be more of that classic red, scaly rash. Then the chronic forms are basically all of the self-inflicted damage of scratching and rubbing, where you get this thickening of the skin and accentuation of the skin line.

Peter L. Salgo, MD: Is it persistent or does it go away and come back? Is it recurrent?

Jonathan Silverberg, MD, PhD, MPH: It’s a fascinating area that we’re learning a lot more about. The old dogma was that most children who get atopic dermatitis, their disease will dissipate by the time they hit adulthood. There have been some very interesting studies that have been published recently that suggest that it may persist more commonly than we’ve realized in the past. Even children who often will have their disease remit in adolescence will find that they’ll get a recurrence later on in life, in adulthood, which can often be particularly difficult for them.

Peter L. Salgo, MD: What it sounds to me, though, with all of this variable presentation—with the fact that it can be affecting young people, older people, extensor muscles, and flexor muscles—it’s unsightly for one thing. It really must affect you. If I’m a teenager with this, I’m not a happy camper. And if I’m an adult and it’s not going away, it’s got to be dramatic.

Jonathan Silverberg, MD, PhD, MPH: Absolutely. There are two broad parts of what bothers patients. There are certainly the cosmetic aspects—the teasing, the bullying—and the issues related to work and relationships. But, actually, what bothers the patients more than anything are the symptoms. You contrast this with some other skin disorders like psoriasis, where there may be more of that visual component. With atopic dermatitis, it’s the itch. It’s the itch and the pain, and they just want to make that go away as fast as possible.

Peter L. Salgo, MD: And my guess is it affects things like sleep. How can you sleep if it’s itching like that?

Jonathan Silverberg, MD, PhD, MPH: You can’t. For most patients, there’s going to be, during an acute flare, dramatic disturbances of sleep where they cannot fall asleep at night. It sometimes takes them hours until they fall asleep. They cannot stay asleep because the itch will wake them up. Once they do wake up, they have these prolonged awakenings. They just can’t get up and go in the mornings.

Peter L. Salgo, MD: As a parent of three school-age kids, what my concern would be is my kids can’t get a good night’s sleep. They can’t work well at school the next day. They can’t focus on their homework. It’s a disaster.

Jonathan Silverberg, MD, PhD, MPH: Absolutely. So, unquestionably, it’s a big problem with respect to school performance and work performance for our adult patients, as well, and there are problems in terms of extracurricular and recreational activities. Interestingly, it’s a big problem for the parents themselves because when the child is up all night, awake scratching, unable to sleep, crying from being itching and in pain, the parents don’t sleep as well. They also have poor work performance.