Growing Pains: Addressing Atopic Dermatitis in Adolescents

Announcer:
You’re listening to DermConsult on ReachMD, and this episode is sponsored by Pfizer. Here’s your host, Dr. Charles Turck.

Dr. Turck: 
Welcome to DermConsult on ReachMD. I'm Dr. Charles Turck, and joining me to discuss the unique challenges of managing atopic dermatitis in adolescent patients is Dr. Adelaide Hebert. She's a board-certified pediatric dermatologist and the Chief of Pediatric Dermatology at Montgomery Medical School at UT Health Houston and Children's Memorial Hermann Hospital. Dr. Hebert, thanks for being here today.

Dr. Hebert: 
Thank you, Dr. Turck, happy to join you.

Dr. Turck: 
Well, to start us off, what makes adolescent atopic dermatitis clinically and psychosocially distinct from the experience of children on the one hand and adults on the other?

Dr. Hebert: 
Well, this is definitely a unique cohort of patients that I see on a regular basis in my clinic. Adolescents have many challenges at this time point in life. They have hormonal changes, which, of course, can be favorable or unfavorable, depending on how they approach these changes. We also know that there is a bit of autonomy coming into play here. They want to break away a little bit from the parental oversight. They want to do things themselves. Many of these children can't yet drive, of course, so they are reliant on their parents to assist with getting the prescriptions, getting to the doctor, and so forth. That lack of autonomy plus hormone changes can lead to really some interesting interpersonal relationships, both between the parent and the child, and between me and the child.

So we try to address that very proactively. We respect the child's feelings. We listen to the child. I try to sit down, be at their height, find out what they're interested in. I don't necessarily start the conversation with the disease state. I might ask them how they're doing. How is their general health? Are you happy to be here today? I also thank them for coming; I think that's an important step. There was a recent article in JAMA that said the happiest patients that you have in seeing you are those that understand that you're happy to see them. So I try to begin with, or at least at some point in the visit, say that I am happy to see them, and that we're going to have a discussion today about how we can improve their overall skin health.

Dr. Turck: 
Looking at a prevalent challenge facing this age group, would you share some common barriers to treatment adherence and how providers might help them overcome those?

Dr. Hebert: 
Definitely. I would say, first and foremost, the teenage male has a real challenge in putting topicals on their skin. It's nothing against the teenage male, it's just a natural thing. They're not brought up to apply creams. They don't think about beauty, perhaps, in the same way that our young female patients do. And there is often reticence to adhere to some of the protocols that really do necessitate the use of moisturizers or the application of topical agents to rectify their atopic dermatitis. So, in those cases, we take that into consideration, and we try to address an approach that is going to be meaningful to them in controlling their disease, but also one that they can appreciate and use effectively to achieve the outcome that we're both hoping to achieve. For the female patient, we might indeed have an easier time getting them to use topicals, to moisturize regularly, and to use the bathing products that we recommend.

We do have to keep in mind that this population is often involved in sporting activities or band activities, so they're either outside in the cold or the hot, wearing uniforms that might not be so comfortable. So they have some special challenges. And again, we try to ask about those, put those into the perspective, and again, align our treatment regimen with one that's going to be meaningful, practical, and actually doable for these patients during their adolescent years.

Dr. Turck: 
For those just joining us, this is DermConsult on ReachMD. I'm Dr. Charles Turck, and I'm speaking with Dr. Adelaide Hebert about optimizing care for adolescents with atopic dermatitis.

So, Dr. Hebert, let's turn our attention now to systemic treatments. When is it appropriate to consider going beyond topical therapy in adolescents, and what patient-specific factors guide that decision?

Dr. Hebert: 
Well, that's a question I really think that I face on a daily basis. First and foremost, I see many patients in the adolescent realm that are really undertreated. If the patient has moderate-to-severe atopic dermatitis, using an over-the-counter hydrocortisone is simply not going to bring that disease state into a realistic improvement status. So I talk about, what is the patient interested in having? Are they interested in using, let's say, one of the new topicals? We have three; each one is steroid free, they're easy to use, and we usually can get them covered on most insurance plans.

Do they want to go to a systemic medicine, such as a biologic agent, that typically will require that they receive an injection? Some of the adolescents are willing to undergo that therapy; some absolutely draw a hard and fast line that an injection is out of the question.

Our third therapeutic option would indeed be if we wanted to use a JAK inhibitor. Now, that's not without some pain, because we do need to do blood work, both before and during the management strategy with our oral JAKs.

Again, listening to the patient, discerning how we can bring their disease under better control—these are the factors that really influence my decision-making. We know that going to a biologic or a JAK inhibitor generally will bring the patients’ atopic dermatitis under better control. Often, this success is associated with greater compliance, because the patient sees that they get better, and they feel that they get better.

Dr. Turck: 
Now, to bring this all a little bit more to life for us, I was wondering if you would share a patient case that not only illustrates your decision-making process, but also how you navigated the conversation with the patient? I'm trying to get a sense of how you helped them understand and feel comfortable with the treatment plan.

Dr. Hebert: 
Glad to do that. Actually, today in my clinic, I had a young man who is very athletic. He's been my patient since he was a small child. In the earliest days, we did not have the available therapies that we have today. Now, we've been through the topicals for this young man. He simply was not compliant. He lifts weights, he's very active athletically. So we have ultimately gone to a biologic agent, and his response has been absolutely remarkable. He doesn't love the shot—he's the first to tell me that—but he does love the outcome that we've been able to achieve. In addition, he actually has prurigo nodularis and he also has asthma. We've actually brought many domains under control by the use of a drug, which, although he must take an injection every two weeks, he's really happy to do that. It has simplified his life, but more importantly, it's improved his quality of life and his disease control.

Dr. Turck: 
Now as a follow-up to that, what's your approach to balancing patient autonomy versus family involvement in treatment planning for adolescents?

Dr. Hebert: 
Well, I do try to direct the majority of my discussion to the patient. I want to hear what they're experiencing. I want them to feel that they have been heard. Too often, I've actually heard from my own adolescent patients that they go to the doctor, and the doctor only talks to the parent. That doesn't resonate with today's adolescents. They really want to feel that they are empowered. It doesn't mean I'm tuning out the parent altogether; I certainly will have sort of the summary discussion with the parent or discuss with the parent as we go along where I think we're going with our therapeutic plan. But I do try to discuss with the patient, what

are they actually going to use? What's realistic for them? Is a shot simply out of the question? Can they take pills? You'd be surprised at the answers you get from even some of your patients in the 15, 16, 17-year-old age group. Some can take things, and some absolutely will not accept a systemic drug, either because of the blood draws or because of the shots, and they will use the topical because they want to stay away from painful options. But again, including the patient, I think, is really one of the initial steps that helps to ensure success with a therapeutic strategy that will ultimately help the patient.

Dr. Turck: 
Now, as we near the end of our program, Dr. Hebert, do you have any final takeaways you'd like to leave with our audience?

Dr. Hebert: 
I certainly do. There are a couple of things with the adolescent age group I want to remind my colleagues across the medical spectrum regarding. We do have the option to send many of these patients in this age group to a free camp, Camp Discovery. That's one thing the American Academy of Dermatology offers. There is no cost. These children get to experience other children that have skin disorders. Many of them go on to become counselors—again, no cost. That's a big play, and many of these children were afraid to go to camp because they didn't want to expose their skin. They really didn't have the chance to be a kid like other kids attending summer camp because of the embarrassment and self-consciousness they felt about a very visible skin disorder. This allows them freedom. They often make friends, and those friends tend to be lasting friends.

Additionally, I want to remind you, I think it's really important to thank the patient for letting you be their healthcare provider. I just say, “Thank you for letting me take care of you.” And of course, when they come back after I've initiated the therapy and they're doing much better, I just want to thank them for letting me bring them to a state of successful atopic dermatitis management. They feel very proud that they have accomplished so much in the interval between the visits when they have seen me.

So again, thanking the patient, reminding them about Camp Discovery—these are things that I try to bring forward when I sum up my visit with the patient, because I think it's very meaningful for them.

Dr. Turck: 
Well, with those insights in mind, I want to thank my guest, Dr. Adelaide Hebert, for joining me to discuss how we might tailor atopic dermatitis treatment to meet the age-specific needs of adolescents. Dr. Hebert, it was great having you on the program.

Dr. Hebert: 
Thanks so much. Glad to join you.       

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This episode of DermConsult was sponsored by Pfizer. To access this and other episodes in our series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!