The Evaluation, Diagnosis, and Role of Allergy Testing in Patients With Atopic Dermatitis

In this video, dermatologist Steven Feldman, MD, PhD, speaks with allergist and immunologist Jason Caldwell, DO, and pediatric dermatologist Robert Sidbury, MD, MPH, about atopic dermatitis (AD), including the presentation and physical examination of a patient with AD, the use of antihistamines and adherence to regimens, and what is next for research in the management of patients with AD. 

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Steven Feldman, MD, PhD, is a professor of dermatology at Wake Forest University School of Medicine and a dermatologist at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, NC). 

Jason Caldwell, DO, is an associate professor of pulmonology, critical care, allergy, and immunologic diseases at Wake Forest University School of Medicine and a pediatric allergist at Atrium Health Wake Forest Baptist Medical Center (Winston-Salem, NC).

Robert Sidbury, MD, MPH, is the division chief of dermatology and an associate professor in the Department of Pediatrics at Seattle Children’s Hospital (Seattle, WA). 

TRANSCRIPTION:

Dr Steven Feldman: I'm Steve. I'm on the faculty at Wake Forest University School of Medicine where I'm Professor of Dermatology. I'm joined by my friend, Dr Jason Caldwell, a Pediatric Allergy and Immunology Specialist at Atrium Health Wake Forest Baptist Medical Center and Associate Professor of Pulmonology, Critical Care, Allergy and Immunologic Disease here at Wake Forest. We also have Dr Robert Sidbury, Division Chief of Dermatology and Associate Professor in the Department of Pediatrics at Seattle Children's in Seattle, Washington.

Let's start with the treatment of atopic dermatitis, and we'll talk first about mild atopic dermatitis. I think most people with atopic dermatitis probably just have mild disease. Of course, the people with severe disease are in our office like crazy, but most people probably have mild atopic dermatitis. Robert, what do you start these patients on?

Dr Robert Sidbury: Yeah, I think first with this type of kid, we don't see them much. They oftentimes are in the pediatrician's office and never make it to us. But when they do, maybe a sibling of a patient we're seeing, I always talk first and foremost just about good skincare. Moisturize. A big question is always, "How often should I bathe? I've heard bathing dries out the skin." I don't stress too much about the frequency of bathing. Just try to keep the bath simple, not too hot of water, not too long, 5 or 10 minutes. But most importantly, moisturize immediately afterward, within a few minutes, whether they bathe once a day or once a week. So that's one.

Moisturization is the foundation of atopic dermatitis care and then avoiding triggers. Sometimes it's the foods, as we've talked about, but if they know there are triggers that are causing problems, then just avoid those and oftentimes that's enough for the patients with that milder end of the disease.

Dr Steven Feldman: So when you say triggers in fabrics, I think about laundry allergens. Jason, sir, for mild atopic dermatitis are you recommending any kind of allergen avoidance?

Dr Jason Caldwell: Not necessarily. Again, it would be only if there was a food that the family recognized, I would encourage the avoidance and we just stress moisturization, moisturization, and more moisturization.

Dr Steven Feldman: Yeah, I have the general impression that I see more preventable illnesses caused by fabric softeners and dryer sheets than I do from cigarettes and tobacco combined in my dermatology practice. Jason, are there any other medications that you would be use for mild atopic dermatitis?

Dr Jason Caldwell: Well, I guess mild atopic dermatitis can mean they just have maybe one portion of their body that's affected or maybe the creases of their elbows. If it's affected and it seems to be bothering them, then I would definitely start with topical steroids.

Dr Steven Feldman: And what is the place for the non-steroid topicals?

Dr Jason Caldwell: I guess that I would have to say that I have not used those very much. Some of them cause some sting and children don't like it. Correct use of topical steroids along with the moisturization regimes that we provide in our action plans seem to be just fine and are tolerated very well with low side effects.

Dr Steven Feldman: Robert, do you find yourself using more of those non-steroidal topicals?

Dr Robert Sidbury: I do, but certainly topical steroids are the mainstay for treatment and when they're successful then that's all I'll use. When I see patients come back and they're not getting as much better as I would hoped, I first want to make sure that they're not steroid-phobic. So I have a discussion, as Dr Caldwell has mentioned sort of explaining how they're used safely, that they can be used safely, what the signs and symptoms of overuse might be, and make sure that that's not a barrier to adhering to our treatment plans.

And then when appropriate, I will incorporate the topical calcineurin inhibitors, pimecrolimus, tacrolimus, the topical phosphodeiesterase inhibitor, crisaborole, which is now approved down to three months of age, a time when that steroid phobia rears its head more than any other. But there is no question, some of them can sting and that can be a barrier to their use. We have ways to mitigate that oftentimes. Treat the active inflammation with the steroid, get it better, and then when the rash is just starting to come back, if you need a non-steroid, use it then because things sting less on less inflamed skin.

Sometimes pre-treating with a moisturizer, it changes the known potency of the drug that you're using because you're putting something on first, but it can also still work and yet stop the stinging, put the medicine in the refrigerator. Lots of ways around that stinging sometimes, but it can be a barrier, no doubt.

Dr Steven Feldman: Yeah, sometimes it's helpful to let people know that the stinging is a sign the medicine is working, which it is because it's a sign they put it on. Anyway, now between the moisturizing, the bathing recommendations, the use of steroids and the use of non-steroids, the regimens get pretty complicated. Now I heard Jason allude to having an action plan for patients. Robert, do you have a standard written action plan that you give to patients with atopic dermatitis?

Dr Robert Sidbury: We do. We sort of borrowed it from the asthma world. The asthma action plans for years have been out there and it's critical when there's a multi-step disease that's dynamic. What they're presenting with you in the clinic that day is not necessarily what they'll be presenting at home tomorrow. And so you need to have an action plan that matches both the mild end of the spectrum and the more severe end of the spectrum for that individual patient, whatever that may be.

Dr Steven Feldman: Jason, you're using the same things?

Dr Jason Caldwell: Yeah, we have an action plan that's been taken from multiple different resources. Again, not to repeat myself, but to emphasize the moisturization. We actually do emphasize bathing, but as our colleague said, we want to do moisturization immediately after bathing and put the topical steroids on immediately after. But we definitely print out and give people a plan.

Dr Steven Feldman: Yeah, I have less faith in people's willingness to do things, and so I try to keep the regimens even simpler than that. All right. Let's talk for a moment now about the patients with more severe atopic dermatitis. How do you treat them differently? Robert, let me start with you.

Dr Robert Sidbury: Yeah, well, so first of all, that is where you're going to start making sure there aren't any allergic triggers. When I was talking about the mild end of the spectrum, it was more sort of irritancy and things like wool fabrics that are just scratchy feeling rather than true allergy. But now we're talking about leave no stone unturned to identify anything that you can actually remove and help. But oftentimes we're talking about treatment, just making these patients better.

Whether it's a stronger topical steroid or treatment regimen topically, incorporating bleach baths for instance, wet wraps for instance, maybe even phototherapy, or going on to the systemic medications such as the older school medications like methotrexate, cyclosporine, or the newer ones that are now actually FDA approved like dupilumab down to six months of age. Tralokinumab, another biologic for adults, or the JAK inhibitors. Two of them now, oral JAK inhibitors, approved down to 12 years of age are things that we would then talk about and through shared decision-making to try to match the patient with the best therapy.

Dr Steven Feldman: Jason, you have a favorite of those approaches?

Dr Jason Caldwell: Well, I would like to add in another approach that I'm very keen on picking up, and it's super infection. In the very severe atopic dermatitis, many times they're very erythrodermic. They even may have some oozing. I'm under the impression that unless you can control the infection temporarily, because there's no way to eradicate staph aureus, which is probably the most common cause of super-infection and produces the super-antigens, I really focus at the beginning of my treatment on antibiotic therapy if I think it's necessary.

Dr Steven Feldman: Yeah. So Robert mentioned bleach baths, is that it or you think it's some kind of oral antibiotic?

Dr Jason Caldwell: We use oral antibiotics is what I use for severe patients, which I think are super-infected.

Dr Steven Feldman: And are you culturing them and basing it on the culture or just a relatively broad-spectrum antibiotic?

Dr Jason Caldwell: No, I mean, so no, I'm not culturing. I think previously in my career I did culture a lot, but it just kept coming back as staph aureus, and we use drugs in our office or in our practice we use drugs that are targeted toward staph such as clindamycin or even sulfamethoxazole/Trimethoprim.

Dr Steven Feldman: Yeah. Robert, is that your impression too that these severe AD patients need some kind of antibiotic treatment a lot of the time?

Dr Robert Sidbury: Oh gosh. Well, depending on where you are, 70, 80, 90% are staph carriers. So as Dr. Caldwell says, cultures really don't help you much unless you're worried about resistance and MRSA. So I'm in the same school there. And then whether or not how to treat them when they are infected, it kind of depends upon the extent. If it's just a little local small impetiginized plaque that I might get away with just adding a little topical neopersen, great, I'll do that. If they're multifocal pustules or more extensive erythrodermic, as Dr Caldwell mentioned, then my usual go-to, absent resistance concerns, would be cephalexin.

Dr Steven Feldman: Excellent. Now, we haven't talked about antihistamines yet. Are y'all using antihistamines for these patients?

Dr Jason Caldwell: Certainly, we, at least in the allergy world, use antihistamines. I do think there's some evidence that antihistamines can help. We typically use the non-sedating, second-generation antihistamines such as cetirizine, fexofenadine, and loratadine.

Dr Steven Feldman: Well, that is completely backward from what I was thinking. I was thinking that there was strong evidence that non-sedating antihistamines had no place and that sedating antihistamines were helpful to help these kids sleep through the night. Robert, I'm going to let you be the deciding vote here. Tell me what you're thinking about antihistamine use.

Dr Robert Sidbury: Well, I'm a dermatologist, so this is more a dermatologist perspective perhaps. In general, I use non-sedating antihistamines if I have a patient who has an allergic rhinoconjunctivitis or something that is flaring and that flare then can sort of snowball and seem to trigger their eczematous flares as well. But if we're just talking about an eczematous flare, I will only use antihistamines in the context of the itch causing sleep loss and then I take advantage of the sedation itself.

Dr Steven Feldman: Yeah. Jason, do you want to comment any more about how those antihistamines have been helping your patients?

Dr Jason Caldwell: No, I think that's certainly reasonable. We use antihistamines for several different disorders, and some of the disorders have itching. We can even go at higher doses than what it says on the recommendations if we need to. We're pretty quick to do that as well.

Dr Steven Feldman: Yeah, I think loratadine is approved to 10 milligrams in the United States and 40 milligrams in Europe.

Dr Jason Caldwell: Sure.

Dr Steven Feldman: I'm dosing people heavily with that at times. Well, people with atopic dermatitis have a horrible disease. It's affecting their lives in big ways. So we can pretty much count on them to be adherent to their treatment, right, Robert?

Dr Robert Sidbury: Absolutely. You know that.

Dr Steven Feldman: Robert and I are just joking. I think we got really strong evidence that they're not adherent to their treatment. We talked about using action plans. Is there anything else you do to try to encourage better adherence?

Dr Robert Sidbury: For me, I just make sure that they realize oftentimes, so we talked about steroid phobia. I think that's critical. Just make sure that's not a reason they're not going to do what you're telling them because they're afraid of it. I think thinning of the skin is a good example. That is absolutely a side effect that can occur with topical steroids. But if that's all we tell them, what is that? Does it last? Is it bad? Does their arm fall off if they get thin skin there?

So we have to let them know that thinning of the skin, what it looks like in the first stages, little telangiectasias, totally reversible. Some of you are maybe too young to have this teaching aid of mine, which is this senile thinning on the back of my hand. Even that, you cause a little wrinkling there, that's reversible. Treat through that, you get a stretch mark. So I embrace the fact that they know that they can cause thinning, but I try to let them own the earlier phases of that thinning such that it's reversible and they know it's not a bell they can't un-ring.

Dr Steven Feldman: Jason, do you have any favorite tips for improving adherence?

Dr Jason Caldwell: Well, I think this is where a specialist comes in, either a dermatologist or an allergist in that we are going to spend more time focused on that than maybe if the pediatrician or family doctor is having to go through multiple different problems plus education on multiple different things depending on their stage. And we have the ability to sit with them and go over the action plan. And I try to make sort of a verbal contract with them to do it for at least four weeks. And if they're no better, then we can adjust our plan. If I get buy-in with that, then I think I have some success. But still, of course, compliance is a problem.

Dr Steven Feldman: Your patients must love you. I, as a medical dermatologist, don't spend very much time with my patients, and the regimens we're asking them to do are so complex I try not to ask them to do it for more than three days before they call me to report the progress. I think that short horizon makes it much easier for them to do the treatment. All right, we have so many new drugs coming up. What's next in research for it? What do you see coming for our patients with atopic dermatitis? Robert, I'll let you go first.

Dr Robert Sidbury: Well, first of all, I'll say just now when my patients aren't doing well after three days, I'm going to have to have them call Dr. Steve Feldman. So that's one thing. But what we're doing with these new drugs, I mean the biggest new drugs out there, dupilumab was approved in 2017, now approved down to six months of age. The other biologic, tralokinumab, there may be another one down the pike soon. Lebrikizumab is right around the corner, another IL-13 blocker.

Nemolizumab IL-31 blocker right around the corner most likely. JAK inhibitors, as we talked about, Upadacitinib approved down to 12, abrocitinib approved down to 12 just yesterday, literally. The pipeline has never been fuller for patients with atopic dermatitis and it's really exciting to see.

Dr Steven Feldman: Thank you. Jason, anything else happen in the allergist world that I should know about?

Dr Jason Caldwell: No, I think that just in general, the anticipation of new biologics is probably out there on the horizon. Although I really do think the introduction of dupilumab has been a great success, especially in severe and moderate atopic dermatitis. It's definitely a go-to these days.

Dr Steven Feldman: Outstanding. Anything else to add?

Dr Robert Sidbury: Thanks for listening. This is exciting to talk about this field because we're making progress.

Dr Steven Feldman: It's a pleasure. Thank you.