Transcript
Dr. Naiem Issa: Let me ask you this, Dr. Offiah. Let's talk about atopic derm actually for a second here. I think it's a very common disease state that we are seeing, even more prevalent year after year. Are there any special considerations when itcomes to topical steroid usage or just topicals in general for, let's say, our adultpatient compared to our pediatric patient? What should we consider?
Dr. Maureen Offiah: So for our pediatric patients compared to our adult patients, we really need to consider a medication that will not be absorbed systemically andcause a lot of issues. Our patients have a much higher body surface area-to-mass ratio with the small patients. Their bodies are really small, their skin is a lot more delicate. Still developing, so tends to absorb a lot more. So throw in steroids and they tend to have a greater involvement of rash in atopic dermatitis. Very rarely do you see infants, young children, toddlers that come in and just have just a few scattered patches here and there. Many times they have almost 50% or more of their body surface area involved. So special consideration is, one, thinking of not just aneffective topical agent, but also something that is safe. Yeah, safety applies to all patients regardless of their age, but honestly it is a lot more important, if you will, in our smallest patients. They're absorbing this medication and that's just the truth. We can tell ourselves all that we want, but they are absorbing these medications. Anything that would help this patient have symptomatic relief, be able to sleep better, be able to sleep so they can grow, so they can avoid having things like stuntedgrowth, increased risk of fractures, increased risk of mental health issues as it impacts this patient. These patients, they are the formative years of their life, so us treating these patients, we're treating beyond the skin. We're definitely dictating how these patients are going to develop mentally, socially. They're going to school when they grow up, other children are looking at them, maybe making fun of them. This is all impacting their mental health, causing increased risk of depression, anxiety, ADHD, not to mention everything else that can arise from that. So these are all theconcentrations that we have in our pediatric patients compared with our adult patients.
Now, with our adult patients, one, they come in and therefore they're stunned. They're like, "How did I even have this? Why am I just having this at the age of 60, 70?" So they're totally confused. So really helping, holding their hands and helping them to really understand the chronicity. They have a harder time understanding and accepting the chronicity of intrinsic atopic dermatitis. So if your patient, if you're not having what we call planning and decision-making between you and your patient where you ... Shared decision-making, that's the word I was looking for. Ifyou don't have that shared decision-making, you're not going to succeed with your treatment. You can come armed with all the knowledge of all the great systemics and everything and topicals, but if your patient isn't fully understanding why they had eczema that's literally supposed to be for babies and how they have it and thechronicity of it, understanding how they have to make certain lifestyle modifications, changes to their daily skincare regimen, these are the things that dictate success. So those are some of the considerations that I have in both patient categories.
Dr. Naiem Issa: And you're telling me you do all that in a 10-minute visit? I need to come watch how you do this, because you just blew me out of the water, right?
Dr. Maureen Offiah: This is my secret. This is what I tell patients. On the first day that I meet a patient, I'll be like, "If you don't remember anything from this visit, I need you to remember that you have a chronic skin condition." I tell them, "This is our own version of high blood pressure, lipid issues, cholesterol issues, diabetes. This is our own version in dermatology. This is lifelong. We're not planning to cure this, but I can definitely help control this medication to where you can live a nice, normal life." So I want them to remember that part. And then I also say, "Because of the complexity of this disease, I don't expect you to remember or learn everything about it in just one visit. So this is a longitudinal relationship between us. Every time you come in, piecemeal, you're going to learn something new about your disease. You're going to come in with questions and I will have new information." But it'll be a little bit of information at the time without doing information overload. The patient leaves, they're confused, they don't rememberanything. So I just focus on what really matters, emphasizing the chronicity the first time. And of course, and then as time goes on, I keep teaching the patient about it.
Dr. Naiem Issa: Absolutely. And we're going to hold on that topic for just a second for chronicity and what we should consider from a therapeutic paradigm. But let me just go back to the pediatric patient just really quickly here. I think that's something that we are appreciating more is the morphology or phenotype of what infants look like with atopic derm, as well as the young kiddos and adolescents. So for example, for infants, for those who are, let's say three months of age and a little bit older, these patients, they present with eczema on their cheeks, for example, or the top of their hands. This is interesting because when you're thinking about using topical steroids, these are high impact sites where they can put their hands in their mouth, for example, or they canget it near their eye and so on. So the thought process, not just systemic absorption, but also local cutaneous adverse events, as well as getting it in mucus membranes as well as the eye and so on. So I think there's a special consideration for infants. Andthen on top of that, when you're talking about kids or adolescents, as well as teenagers and so on, where they have them on the antecubital fossa, for example, popliteal fossa, as well as sometimes on the face, or periocular to be exact. You see a lot of that with exacerbation, is that these patients also have a greater ... How do I say it? A greatercollection of the steroid localized in those areas because of the crevices. And add on top of that, you have broken skin. The skin barrier disruption for any patient, thatincreases the absorption, going back to that original concept that you talked about.
