Transcript
Announcer:
This is DermConsult on ReachMD. On this episode, Andrew Mastro will discuss how he approaches sequencing therapies for patients with atopic dermatitis. He’s a board-certified physician assistant at the Illinois Dermatology Institute and DeNova Research in Chicago. Let’s hear from him now.
Andrew Mastro:
There are patients for whom I like to use, or potentially would use, a mid- to high-potency TCS on for maybe the first three to seven days. So it's not as if we go three to seven days TCS and then switch to the non-steroidal; a lot of times I'm overlapping these. And I like to think of that maybe in really tough areas, like the hands and feet, where I really need to put that fire out. In terms of itch, we all have those patients who really need it gone yesterday, and we can depend on these mid- to high-potency topical corticosteroids to deliver that fast result. So for those patients that are either super lichenified, I really just want to really work through that thickened skin or these tough areas like hands and feet. I do like to do a little bit of a bridge, but not for everybody. It really is patient dependent.
But I like to remind my patients—this is really critical—that even with three days of use of a mid- to high-potency steroid, the skin barrier suffers degradation. You already have a degradated skin barrier through atopic dermatitis skin. The skin's not normal. You have a defunct skin barrier in terms of the way your proteins are put together. So ultimately, when you use a mid- to high-potency steroid, that barrier is also being attacked by that corticosteroid. That's why when we're using it for two weeks, three weeks, or four weeks, the barrier is just getting destroyed. And so I like to remind patients, just because I say it's okay to use it for two weeks out of a month, I may not want to use it like that because of that skin barrier problem, especially in atopic dermatitis skin.
And I don't necessarily also mention this point to the patients, but I like to think about the 500-Dalton rule, which is really neat and super nerdy, but I think it really helps contextualize what are we doing with these topicals. So basically, what that means is the 500-Dalton rule goes towards molecules that are under that level have a easier time passing through the skin. So for reference, say clobetasol is, I think, 467 Daltons, so it can pass through that normal level. Atopic dermatitis skin is closer to 900 Daltons, so even more penetration for that clobetasol to get through and less of a barrier or threshold to get into atopic dermatitis skin. The mucosa is 1,200 Daltons. So the concept is this barrier is already broken down. The skin is already at risk, so I don't like to use steroids more than I have to. So it's just an overall kind of just generalized picture.
In terms of TCI, I really don't reach for it unless my access dictates that I have to. But ultimately, for those patients who can't untether from the TCS, I also sometimes will prescribe a TCS with a non-steroid topical like rux and let them know, "Hey, I know that you've sworn by this for all of these months or all these years. This is why we have to transition off. However, I will prescribe this to you. But can you please switch this thought process for me? Instead of using it as your go-to and your hub, can we please just think about this like the fire extinguisher? This is to break glass, and then we can use it for a few days, calm you down, continue on your non-steroidal, and then keep this going." So we have to retrain these patients sometimes into understanding why we don't want them to do some things and why we want them to do others. So it's not just enough to tell them what we want; it's really connecting the why, and then that's when we can start bridging that gap a little bit.
Announcer:
That was Andrew Mastro talking about therapeutic sequencing in atopic dermatitis. To access this and other episodes in this series, visit DermConsult on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
