Topical Therapy Beneficial for Patients With Atopic Dermatitis

Vivian Shi, MD, FAAD, associate professor of dermatology, University of Arkansas for Medical Sciences, highlights clinical scenarios in which a topical treatment for atopic dermatitis may be most effective.

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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.

In the final installment of this podcast series, Dr Shi breaks down costs and looks ahead to the future of atopic dermatitis treatment.

Hello, my name is Vivian Shi. I'm a board-certified dermatologist practicing in Little Rock, Arkansas. I'm currently an academic dermatologist and associate professor of dermatology at the University of Arkansas for Medical Sciences, where I direct the clinical trials operation in my department.

I specialize in atopic dermatitis, as well as other inflammatory conditions such as hidradenitis suppurativa.

As a clinician, what would you want payers to understand about the patients who could benefit most from treatment with Rux cream?

That's a great question. I think a patient would benefit most from this treatment if they have hard-to-treat sites that are sensitive—cosmetically sensitive sites, and sites that have nonsteroidals contraindicated because it’s burning or it's not efficacious enough and/or you can't use topical corticosteroids.

Rux cream is quite expensive, so it would be lathering a very expensive medication all over the body. It may not be economical to do so, but it's quite possible for these special sites, if you're able to get them controlled with Rux cream, it may delay the need or negate the need for systemic therapy, which is much more expensive than RUX cream.

It's definitely patient dependent, but I think we are very limited in terms of efficacy when you look at calcium inhibitors and crisaborole.

What role, if any, do costs play when it comes for you to decide on a therapy option for a patient with atopic dermatitis?

We always think about minimizing costs and maximizing efficacy. But if I'm unable to get a patient under control, they have to get hospitalized, go to the emergency department, or lose their ability to work. I'd rather go for something that's more expensive and then be able to get them under control.

For out-of-pocket costs for Rux cream, the last time I looked at it, it was for 1.5%, as in, what, $2000 for 60 g? It's a lot more than other nonsteroid or anti-inflammatories, but it's still a fraction of the systemic treatment.

So I would probably use this more selectively in the face, the eyelid area, and the underarm scoring folds, and go from there. Most of my patient population doesn’t have the luxury of lathering Rux cream all over themselves like they would with a topical corticosteroid.

As more treatments become available and the landscape continues to change, where do you see the future of atopic dermatitis care heading?

Well, we're heading towards designer medications. They are targeted immunomodulators. Most of the attention has been paid to systemic treatments, like targeting the IL-4, IL-13, and IL-31 pathway, and now we have JAK inhibitors that are more systemic. JAK inhibitors that are more broadly immunomodulating.

I think we still need more efficacious and safer medications. The biologics that target IL-4 and IL-13 are safer than the JAKs, but they work slower. They don't work as effectively as systemic JAK inhibitors, like upadacitinib, for example.

I think patients are looking for monotherapy. In the ideal world, they'd rather not lather a cream every day. If they could have it, they will rather take a pill every day or do a shot every month. That's convenient medication, but there are also people who absolutely don't want blood monitoring, they don't want injections every so often. They're more than happy just to do creams, for as long as they could. It really depends on the patient.

Let's just keep in mind that atopic dermatitis is also very heterogeneous. Some people will have the same severity throughout the entire year. Some will have seasonal flares and some people will have situational flares, like stress induced. Some of them will be environmental triggers.

Having a topical medication is good, because you can apply it when you have a lesion, and you don't have to apply when you don't have a lesion. But, some of the biologic medications, once you are on it, you're on it until you no longer need it for good. The flexibility in dosing with topical medications and oral JAK inhibitors is pretty attractive for my patients.

Is there anything else that we haven't mentioned yet that you'd like to bring up today?

Well, I think we need more head-to-head analysis, looking at systemic drugs against each other. Also, topicals—I would like to see some cost-effective analysis after we have more real-world data with Rux cream, and how that compares to different potency of topical steroids and noninflammatory medications. I'd also like to see whether Rux cream will be an option for other inflammatory conditions, such as hidradenitis suppurativa, etc.

This is an exciting time. We're entering the targeted era of dermatologic treatment. Disease is more terrible than ever, but it's promising. It's gratifying to know that we are empowered with these new efficacious tools to fight back.

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