Dermatologists and primary care clinicians have been able to adequately manage most patients with atopic dermatitis (AD), using long-standing and familiar nonpharmacologic and pharmacologic interventions. However, many individuals have chronic or intermittent AD that profoundly affects their quality of life, and yet remain inadequately treated.
Good skin care—hydration and moisturization—remains a cornerstone of management for all patients, for both acute and maintenance therapy, as is identification and avoidance of irritants that trigger flares. To bring AD flares under control, topical corticosteroids (TCS) often suffice. Topical calcineurin inhibitors—pimecrolimus or tacrolimus—are effective as nonsteroidal anti-inflammatory agents, both as alternatives for flare management (especially in delicate skin areas) and in maintenance regimens. Bacterial colonization and infection should be recognized and managed, and dilute bleach baths may be highly effective.
These strategies have allowed the majority of patients with AD to experience clinical improvement. It is not necessary for individuals with AD to settle for intolerable chronic signs and symptoms, only reaching out to practitioners when AD becomes acute. Recent advances in research have led to a further understanding of the pathogenesis of AD, and the treatment of this disease has evolved. The result is more effective use of standard nonpharmacologic and medical therapies, with newer medications soon to be approved or currently in development. Most individuals can and should be treated to achieve minimal disease, minimal rashes, and minimal pruritus.
Several new and emerging agents, which target immunologic pathways in AD, are now or will soon be available and represent the next important step in the evolution of treatment. Crisaborole, a topical phosphodiesterase-4 (PDE-4) inhibitor that mitigates the inflammatory process of AD, recently was approved by the US Food and Drug Administration. Dupilumab, a systemic agent that has been studied in phase III clinical trials, is an inhibitor of the interleukin (IL)-4 receptor α subunit, which results in inhibition of both IL-4 and IL-13 signaling. Other immunomodulators, such as Janus kinase inhibitors, are being investigated in AD.
The newer immunologic agents join the standard, familiar strategies to provide extended disease control and an expanded expectation for an improved quality of life for patients with AD.
Lawrence F. Eichenfield, MD
Chief, Pediatric and Adolescent Dermatology
Professor of Dermatology and Pediatrics
Rady Children’s Hospital, San Diego
University of California, San Diego School of Medicine
San Diego, California
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Participants should read the activity information, review the activity in its entirety, and complete the online post-test and evaluation. Upon completing this activity as designed and achieving a passing score on the post-test, you will be directed to a Web page that will allow you to receive your certificate of credit via e-mail or you may print it out at that time. The online post-test and evaluation can be accessed at http://tinyurl.com/meetingthechallengeofatopic. Inquiries about CME accreditation may be directed to the University of Louisville Office of Continuing Medical Education & Professional Development (CME & PD) at firstname.lastname@example.org or (502) 852-5329.
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The diagnosis of atopic dermatitis can be challenging because the type and appearance of skin lesions can vary and some common cutaneous conditions—such as seborrheic dermatitis (“cradle cap”) in infants—may coexist. In most cases, attention to characteristic features of AD leads to the correct diagnosis. Awareness of clinical circumstances that should lead to consideration of some rare conditions in the differential diagnosis also is important.
Recently published studies that have furthered the understanding of the role of filaggrin, filaggrin gene mutations, and transepidermal water loss have demonstrated that daily, full-body emollient applications, beginning at birth, may prevent the expression of AD in susceptible children. For all patients with AD, the use of adequate skin hydration combined with the prompt application of ointment or cream moisturizers (“soak and seal”) remains the cornerstone of AD therapy.
Recent advances in understanding the complex pathophysiology of AD have led to the development of new and emerging topical and systemic medications that may effectively manage the signs and symptoms of AD in patients who do not respond adequately to standard treatment regimens. These include the topical phosphodiesterase-4 inhibitor crisaborole, recently approved for use in AD by the US Food and Drug Administration (FDA), and the subcutaneously administered interleukin-4 receptor α subunit inhibitor dupilumab, for which phase III pivotal study data are now available.
Clinicians must remain up-to-date on the findings from clinical studies on the diagnosis and management of AD, as well as the benefits and risks of all treatment options available, to make the appropriate choices for management of their individual patients.
By reading and studying this supplement, participants should be better able to:
- Discuss the features of AD that should allow a clinical diagnosis of the condition in most patients, and list the factors in children and adults that should lead to the consideration of alternative diagnoses or identification of comorbid conditions.
- Explain how the current understanding of the role of the epidermal skin barrier and transepidermal water loss should affect—and continue to improve— the day-to-day care of patients with AD.
- More effectively individualize patient treatment strategies by considering the full range of current and emerging therapeutic options.
- Consider the evidence-based recommendations in the current guidelines for the diagnosis and treatment of AD published by the American Academy of Dermatology.
- Describe the rationales and mechanisms of action of the new and emerging therapies for AD, particularly the recently approved topical agent crisaborole and the systemic medication dupilumab (phase III study results under FDA review at the time of publication of this supplement).
Individuals in a position to control the content of this educational activity are required to disclose: 1) the existence of any relevant financial relationship with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients with the exemption of non-profit or government organizations and non-health care related companies, within the past 12 months; and 2) the identification of a commercial product/device that is unlabeled for use or an investigational use of a product/device not yet approved.
Lawrence F. Eichenfield, MD, Advisory Board/Speaker: Valeant Pharmaceuticals North America LLC. Consultant: Anacor Pharmaceuticals, Inc./Pfizer Inc., Eli Lilly and Company, Genentech, Inc., Otsuka America Pharmaceutical, Inc./Medimetriks Pharmaceuticals, Inc., Sanofi Genzyme/Regeneron Pharmaceuticals, TopMD, Valeant. Investigator: Sanofi Genzyme/Regeneron.
Linda F. Stein Gold, MD, Consultant: Anacor. Grant/Research: Anacor, GlaxoSmithKline. Data Monitoring Committee: Otsuka.
Staff and Advisory Board Disclosures: The CME & PD staff pediatricians, family practitioners, and Advisory Board have nothing to disclose.
CME/CE Reviewers: Cindy England Owen, MD, Assistant Professor, Division of Dermatology, University of Louisville School of Medicine, has no relevant financial relationships to disclose. The PIM planners and managers, Trace Hutchison, PharmD; Samantha Mattiucci, PharmD, CHCP; Judi Smelker- Mitchek, MBA, MSN, RN; and Jan Schultz, MSN, RN, CHCP, have nothing to disclose.
Global Academy for Medical Education Staff: Sylvia H. Reitman, MBA, DipEd; Jenny Campano; Tristan Nelsen, MNM, CMP, HMCC; and Joanne Still have no relevant financial relationships to disclose.
Off-Label/Investigational Use Disclosure
This CME/CE activity discusses the off-label use of certain approved medications as well as data from clinical trials on investigational agents. Any such material is identified within the text of the articles.
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