Atopic Dermatitis: Sleep Disruptions, Stress, Anxiety, and Activity Impairment Are Difficult for Adolescents

Atopic dermatitis (AD), often referred to as eczema, occurs in a range of severities. Even in its mildest form, it can be annoying and intrusive. In its moderate to severe form, AD can be life-changing. Symptoms include sore, itchy, and painful skin, which can cause patients to experience sleep disturbances, withdraw from social activities, and miss school and work. Among the approximately 15% to 30% of infants and children who develop AD, about 20% will continue to experience symptoms through adolescence. Adolescents have unique concerns and adherence issues, and that was the topic of a presentation given by Steven A. Scott, PharmD, associate professor of pharmacy practice at Purdue University College of Pharmacy, and Cari W. Pao, PharmD, MSHCM, MBA, senior clinical director of health outcomes, at the recent National Association of Specialty Pharmacy Annual Meeting and Expo in Washington, DC.

Dr Scott reminded reminded audience participants that AD is part of a triad of atopic diseases. Many adolescents who have AD will also have asthma and allergic rhinitis. Researchers have identified a genetic predisposition, but there are numerous AD triggers. Environmental irritants and allergens can cause or contribute to AD, and harsh soaps and detergents are particularly irritating. A variety of inflammatory mediators including interleukin (IL)-4, IL-5, and IL-13 have been implicated in the pathogenesis of AD, too.

The presentation of AD in adolescents is somewhat different than in infants and children. The face, neck, and cheeks are less prominent sites of inflammation, and the flexor surfaces of the arms and legs are much more likely to be involved. By the time individuals have had AD for several years, they experience excoriation and lichenification from chronic scratching. Dr Scott noted another significant change between AD in children and AD in adolescents and adults: When AD continues into adolescence and beyond, the likelihood that it will be moderate or severe increases.

Dr Scott indicated that adolescents face unique quality-of-life issues. Often, they deal with significant social pressures and body image concerns. Sleep disruptions, stress and anxiety, and activity impairment are particularly difficult for teens. He stressed that it is critical to use a stepwise approach to management of AD, with the basis of the approach being consistent use of emollients.

The most important treatment outcome for adolescents with AD is symptomatic relief to control itching. Once itching is under control, patients want skin lesions to heal. Therefore, the treatment team needs to remind patients that they must avoid or minimize triggers to prevent future exacerbations. These goals are best accomplished with, again, emollients; topical corticosteroids; and, sometimes, one of the several topical corticosteroid alternatives. Options include calcineurin inhibitors and crisaborole.

In patients for whom these options do not work or those with more severe illness, clinicians will consider phototherapy, oral systemic drugs, and injectable biologics. Systemic agents (azathioprine, apremilast, cyclosporine, methotrexate, and mycophenolate mofetil) present some risk of potential adverse drug reactions and require frequent monitoring. None of these has FDA approval for AD, and at this time, the FDA has approved only 1 biologic, dupilumab. Dr Scott reviewed its mechanism of action, which is IL-4 and IL-13 directed. Dupilumab is indicated in the adolescent population (patients must be at least 12 years of age), and it can be used as add-on maintenance treatment. It is also approved for moderate to severe asthma and chronic rhinosinusitis with nasal polyps. Dr Scott noted that the newer agents, although more costly, have also been associated with fewer adverse effects and less frequent monitoring than the older, systemic drugs.

Dr Pao led the second half of the presentation with a discussion on the economic impact of AD, indicating that its incidence has increased 2- to 3-fold in industrial nations over the past few decades. She underscored that it is critical to talk to patients about AD because it is largely underdiagnosed in adolescents and adults. In her dissection of the various cost contributors to AD, Dr Pao discussed the indirect costs related to lost workdays, sick days, and loss of productivity. She covered a study by the National Health Interview Survey that found that people with AD have out-of-pocket costs between $371 and $489 higher than individuals who do not have AD. This condition is more costly than diabetes or hypertension, as patients must absorb costs related to office visits, prescription medications, and OTC skin care products. In addition, these patients are more likely to be hospitalized than patients with psoriasis.

Patients face numerous barriers related to medication access and pharmacists are critical to help overcome these. Dr Pao indicated that most payers cover biologics if clinicians follow step therapy, but they do limit dupilumab’s use to individuals with moderate to severe AD. The typical records required for dupilumab therapy are documentation of a 4-week trial of a moderate to high potency topical corticosteroid followed by 6 weeks using an alternative agent. She stressed that it’s critical to document intolerance, inadequate response, or a contraindication to these therapies.

Dr Pao rounded out the session by discussing the pharmacist’s responsibilities in this disease. She encouraged pharmacists to discuss drug treatments and adverse effects thoroughly with patients and review how to take, apply, or inject medications. When dispensing topicals, pharmacists should ensure the proper amount of tubes are dispensed for the intended body surface. She stressed that patients need to know what to do if they miss a dose, and be familiar with storage and stability requirements, especially with the biologics. Finally, pharmacists need to ensure that patients are aware that the bathing and cleansing routines recommended early in the course of their disease need to be followed throughout life and that chronic use of emollients is a necessity.