Q&A: Optimal Management of Moderate to Severe Atopic Dermatitis in Tweens and Teens

Key Takeaways

• Effective interdisciplinary care should be used to optimize and individualize treatment for tweens and teens with moderate to severe atopic dermatitis and related comorbidities.
• To enhance clinic visit time with younger patients, incorporate comorbidity assessment tools into the electronic health record to allow patients to complete forms before the visit.
• A simple screening question can help identify depression, anxiety, and suicidal ideation in patients with moderate to severe atopic dermatitis who may be at risk for these comorbidities and require referral.

In this commentary, Robert Sidbury, MD, MPH, and Jonathan Silverberg, MD, PhD, MPH, answer audience questions about screening and management of tweens and teens with atopic dermatitis (AD) from the recent CCO webinar series titled, “Optimal Management of Moderate to Severe Atopic Dermatitis: Infants, Adults, and Everyone in Between!”

In your practice, how is screening for and management of common comorbidities in tweens and teens with AD handled?

Robert Sidbury, MD, MPH:
The good news is that some of the medications used to treat moderate to severe AD, such as the biologic dupilumab, also are used to treat the comorbidities we see in the clinic. For example, dupilumab also is used to treat some types of asthma. For scenarios like this, using therapies that can target or address several problems at once can help optimize and individualize a regimen while simultaneously consolidating costs, dosing frequency, and overall therapeutic burden.

Some patients with AD also may have trouble concentrating in school, and studies have shown that attention-deficit/hyperactivity disorder (ADHD) is overrepresented in patients with AD and that there is a greater risk of developing ADHD in patients with AD. Therefore, it is important for healthcare professionals, parents, and teachers to realize that although young patients with AD often lose sleep because of their itch, they can have inattention at school for other reasons and may require a separate diagnostic evaluation and treatment for something entirely differently from AD.

The other really critical comorbidities—from both pediatric and adult perspectives—are depression, anxiety, and suicidal ideation. There is a global epidemic of these comorbidities in tweens and teens in general, and patients with moderate severe AD are at greater risk. Many healthcare professionals may be understandably leery of delving into these comorbidities because they are not their area of expertise, but I think that asking a simple screening question and identifying the possibility of depression, anxiety, and suicidal ideation—and then involving the patient’s pediatrician or appropriately triaging acute cases to the emergency room—can save lives and is well worth the time.

Jonathan Silverberg, MD, PhD, MPH:
Because I practice in an academic setting, I am a big proponent of interdisciplinary care. Therefore, I screen for several comorbidities. Currently, I use the Asthma Control Questionnaire 6 score to assess asthma, as it includes reliever use. I use the Hospital Anxiety and Depression Scale to measure anxiety and depression because I can get information on both components. These assessment tools can be built into your electronic health record, and because the patient can complete the assessments before they come into the office, you will have all of the information you need without spending 20 minutes of visit time asking those questions.

We have had patients with suicidal ideation who attempted suicide 2 or 3 times because of their AD, and we want to be able to assess how they are doing. As dermatologists, we may ask why mental health is now in our wheelhouse, but if we establish the appropriate therapy, we often will improve the patient’s mental health symptoms.

If I see that the person is depressed, is not sleeping well, and has other issues, I consider this a red flag indicating that I may need to step up therapy and do a better job. If they get better with those therapies, great. If they do not feel better, then I know I should refer them to a specialist. In my opinion, this is within our wheelhouse. The same could be said for eczema symptoms. If you identify patients who have uncontrolled allergic disease, then those patients would benefit from a referral to our allergy colleagues.

What insurance coverage hurdles have you seen in your practice, and how have they been managed effectively?

Robert Sidbury, MD, MPH:
I find that good documentation is an effective tool when working with insurance. In the past, I would say that a patient has bad eczema and I want drug X, but that no longer works. You must speak the language of the clinical trials, and that is why the data we presented in this program are so useful. For example, a healthcare professional could state that they have a patient with severe AD with an Investigator Global Assessment score of 4 and include documentation of their sleep loss, their affected body surface area, and the impact AD is having on their quality of life. Including all of the therapies the patient has tried and failed is going to check all the boxes that might otherwise come back to you in the form of a question or a denial.

Jonathan Silverberg, MD, PhD, MPH:
I would add that if you are starting a patient on one of the newer advanced therapies, most of them have companion patient assistance programs. These programs are invaluable for patients in terms of out-of-pocket costs, so have patients fill out those forms in the office while they are there. It is very hard to track patients down after they leave the office, and getting patients plugged into those programs becomes essential for them to gain access.

Your Thoughts?
What are your thoughts and questions on the use of novel therapies in the management of moderate to severe AD in tweens and teens? Please answer the polling question and join the conversation by posting a comment in the discussion section below.