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Payel Gupta, MD (Host): Atopic dermatitis or AD affects all races and ethnicities, but certain groups have experienced greater social or economic barriers to diagnosis and treatment. The goal of the Moving Towards Equity podcast series is to raise awareness of the challenges, strategies, and resources for moving the needle towards equitable immunology care for all patients and practitioners in all communities.

Welcome to the podcast series from the American College of Allergy Asthma and Immunology. I'm Dr. Payel Gupta. And in this episode, we will discuss improving access to treatment and special considerations in patients with skin of color in atopic dermatitis. Joining me are Dr. Anil Nanda and Dr. Andrew Alexis. Dr. Nanda is in private community practice at the Asthma and Allergy Center in Louisville and Flower Mound, Texas, and is a Clinical Associate Professor of Medicine at the Division of Allergy and Immunology, the University of Texas Southwestern Medical Center in Dallas, Texas.

Dr. Andrew Alexis is the Vice Chair for Diversity Inclusion for the Department of Dermatology and a Professor of Clinical Dermatology at Weill Cornell Medical Center in New York City. He is the former Chair of the Department of Dermatology at Mount Sinai Morningside and Mount Sinai West. Having served as Director of the first of its kind Skin of Color Center for over 15 years, his work has helped to advance patient care, research and education pertaining to dermatologic disorders that are prevalent in populations with skin of color. Thanks again for joining us today, doctors, I'm so excited to have another conversation with both of you.

Andrew F. Alexis, MD, MPH (Guest): Thank you. It's a pleasure to be here.

Anil Nanda, MD (Guest): Yeah. Appreciate it. Me too. Thank you. Doing great.

Host: Great. So let's get this conversation started.

Dr. Alexis, I really wanted to have us all think about your general recommendations and treatment considerations in particular for patients with skin of color atopic dermatitis.

Dr. Alexis: Sure I'd be happy to. In my view, early treatment is so important for all patients with atopic dermatitis, but has specific implications in patients with skin of color. The earlier and more effectively we treat atopic dermatitis in patients with skin of color, the more likely we are to minimize the frequency, severity and duration of these sequelae, including pigmentary sequella and development of prurigo nodularis in severe cases. It's also important to treat atopic dermatitis as a chronic disease, as we all know, because as a chronic disease, it's important to move away from just episodic management of flares, to a more continuous, longitudinal control of this condition, such that we can improve the patient's quality of life in the long run and reduce the chances for these pigmentary sequella and prurigo nodules, and other long-term sequela that we see at disproportionately higher rates in patients with skin of color.

I will add that we can do this more effectively than ever before with safe and efficacious, non-corticosteroid medications, such as dupilumab, crisaborole, topical calcineurin inhibitors among others. These non-corticosteroid options can very effectively manage the chronic disease over time. Another important consideration is that with respect to corticosteroid therapy, we know that among the various potential side effects of topical corticosteroids is hypopigmentation, and due to the greater contrast between normal skin and hypopigmented skin among patients with skin of color, hypopigmentation related to corticosteroid use has a greater burden and is more disfiguring among patients with darker skin types. So with that in mind, careful management of the duration of application of a potent super potent topical corticosteroids is particularly important.

Now, if patients need corticosteroids to manage flares, I would prescribe them for two week intervals, typically followed by two weeks of a non-corticosteroid therapy. That's one approach, and this cycle can be repeated if patients need corticosteroids again, to manage their flares. In general, we have to be mindful of using corticosteroids appropriately by limiting their duration and educating patients to apply them directly to the specific lesions where the treatment is indicated and not indiscriminately onto non-lesional skin.

I will add that while there is corticosteroid phobia among our patient populations, it's also important to address that with patients and assure them that when used appropriately they're very safe and effective, but the key word is appropriately. Now, in addition to treating the typical signs and symptoms of atopic dermatitis, including itching, scaling, erythema, and excoriation, clinicians will also need to manage the persistent pigment alterations that we see in patients with skin of color.

Another important consideration is dry skin, which may be a greater burden for patients of color, especially those who self identify as Black. Part of this is the cultural implications of having visibly dry skin.

Host: Again, so much helpful information. Thank you so much. Anil, did you want to make any comments on everything that Dr. Alexis has just outlined for us? Is there anything that you, in particular in your office or clinic, emphasize with your patients?

Dr. Nanda: I think one of the things just to emphasize, is the patient education, just spending a little more time with patients at least five minutes, extra time just going over all the different therapy, different moisturizing agents Even going into the bags that patients bring of all their medication.

A lot of times patients, they're thinking their topical steroid is the topical moisturizer and vice versa, you know, the moisturizer, the steroids. So even just a little bit of basic education, can help and really make a difference to our patients.

Host: Absolutely all really good suggestions. And I think one thing that I do in my practice is I make sure that patients don't have refills on their topical steroids. I usually like to know how frequently or how much of the topical steroids they're using, especially if I've prescribed something that's more potent.

And then Dr. Alexis, mentioned some of the newer therapies that are emerging, can you talk about them and tell us how you see them fitting in with patients with skin of color?

Dr. Alexis: Sure I'd be happy to. I think that the expansion of our therapeutic armamentarium that we've seen over the past few years has and will continue to help us more effectively managing atopic dermatitis in our patients with skin of color, in particular. The ideal goal of treatment for all our patients with atopic dermatitis is to have longitudinal control of the condition, such that the frequency and severity of flares are minimized and any psychosocial or functional impairments related to atopic dermatitis are improved.

This is particularly important in my view, when we think about our atopic dermatitis patients with skin of color because poorly controlled atopic dermatitis is associated with additional sequellae of post-inflammatory dyspigmentation in this patient population, which may further contribute to the adverse impact on quality of life. We know that studies have shown that atopic dermatitis in skin of color populations is more likely to be poorly controlled and result in absenteeism as well as greater number of ambulatory care visits, as well as a number of other disparities. With the above in mind, our newer therapies offer safe and effective control of atopic dermatitis with improvement in overall severity as well as in patient reported factors, such as pruritis, sleep and quality of life.

These therapies include the injectable biologics that we heard about already from my colleague, Dr. Nanda, and these biologics can target IL4 and IL13 as in dupilumab or IL13 alone as in tralokinumab, which is recently approved. A topical JAK inhibitor also recently on the market in the US called topical ruxolitnib and oral JAK inhibitors, including abrocitinib and upadacitinib, also recently coming into our therapeutic armamentarium.

So this broader range of options will allow us to provide more effective longitudinal control and move away from this rollercoaster ride of episodic care and putting out the fires of intermittent flares, which really adversely affects the quality of life and contributes to higher rates of dyspigmentation in patients with skin of color.

Host: Yes. And actually to our patient again, Mackenzie, she really voiced the pigmentary concerns in her discussion also. And we have a little clip from her that I'd like to play for everyone.

1: even

in areas where I'm like The most itchy is like the back of my neck.

I have a darker area right there. And then I also, in addition to dark and areas, some of my medication, like the. Oh, wait a minute. I mentioned earlier, it believed one of the side effects, is potential lightening of the skin or darkening of the skin, depending on sunlight. So on top of that, I also have to be wary of how long I'm in the sun And constantly packing sunscreen with me and covering those certain areas where I do have eczema to.

Host: So as you can see, hyper and hypo pigmentation, as we've mentioned is a concern for patients. And, can you talk about Dr. Alexis first can you just talk about the options for a patient who wants to treat atopic dermatitis associated pigmentary changes. What do we do? have?

Dr. Alexis: It is challenging to treat pigmentary complionsicat because many of the agents that we use to manage hyperpigmentation also have some potential irritating characteristics or agents that can be potentially irritating to the skin. So for skin that is highly reactive and sensitive to many products as atopic skin typically is, we are somewhat limited on what we can use for our patients with atopic dermatitis who have hyperpigmentation that. That doesn't mean we cannot manage the hyperpigmentation. It just requires, some careful considerations. My approach generally consists of ensuring that the areas of hyperpigmentation are completely devoid of any active inflammation. Clinicians should make sure that eczema lesions have completely resolved and then managed with therapy in a particular area. And only the hyperpigmented patches are treated with bleaching agents. That's to say that we're not treating active eczematous lesions with topical hydroquinone containing agents, for example. I like to check to make sure that the lesion is hyperpigmented patch is completely flat. I have the patient even verify, so they understand how to differentiate between a inactive area that is just with post-inflammatory hyperpigmentation versus another area that may still be partially active and still requires anti-inflammatory or immune mediated therapy before using a topical hydroquinone. Now some strategies to mitigate the risk of hypopigmentation include limiting the duration of corticosteroids to the appropriate duration of two to four weeks. Then switching to non-corticosteroids. And for topical therapies, I typically treat patients with a corticosteroid for two weeks, switch over to a topical calcineurin inhibitor or a topical PDE4 inhibitor.

And for patients with moderate to severe disease who needs systemic or biologic treatment, dupilumab can help to limit the need for topical steroids in the long run. Phototherapy, can also help to resolve hypopigmentation, while treating the atopic dermatitis at the same time. That's one consideration.

And finally, with back to hyperpigmentation, an agent with a little bit less irritation potential is azelaic acid and that can be used off label. Often combined with a corticosteroid to help improve areas that are resolving with hyperpigmentation.

Host: And what have you found are some of the barriers to obtaining some of these newer therapies or, in general, atopic derm therapies, especially in underserved patients that we encounter.

Dr. Alexis: Yeah. So you touch on a very important point about challenges in terms of access to some of these newer therapies. In fact, a recent study identified racial, ethnic disparities in access to many frontline therapies for atopic dermatitis, with Black atopic dermatitis patients in the US receiving fewer prescriptions for dupilumab, topical calcineurin inhibitors, crisaborolel, and some topical corticosteroids even. So limited formularies and other factors can contribute to access barriers. And this appears to disproportionately affect populations of color in the United States.

Host: there is this kind of underlying theme of not even trying to get a medication approved because we're already nervous about the exorbitant paperwork and back and forth that we're going to encounter.

And from previous experience, you know, just thinking that it's just not going to be covered, so what's the point. And I think that, we need to shift that in so many ways, but I think as insurances understand that more and we have more of a discussion about it within our community, we can really help, hopefully change the way that all of that's being done, from the top level down. If that makes sense.

Dr. Alexis: I think that something we can do individually is to go the extra mile for our patients and try and write appeal letters when things are denied. And we all recognize that this can be administratively challenging depending on the setting we work, but doing best we can to advocate for our patients to get the best treatment for them.

Dr. Nanda: I think you bring up a great point. It's almost like sometimes a sense of defeatism. You're like, well, you know, the insurance may not be good, so why even try? But I definitely agree with both of you, you definitely have to try and really utilizing things like samples is very helpful. At least getting patients started, particularly the biologic medications and the newer ones.

educating our staff to provide culturally competent care,

establish trust with the patients and families, addressing language barriers,

and really a strong,

provider, physician-patient relationship.

and then having,

atopic dermatitis treatment plans.

translated into Different languages, including Spanish and things.

can be very helpful.

my staff,

speaks Spanish, so that actually helps a lot of my,

Spanish-speaking patients.

so really broadening,

things

for patients,

is very important. The other kind of things just to look at is a broadening as individual physicians, trying to improve our access on different health plans. I'm trying, it's very difficult, of course, in, in private practice and other practice setting than the academic getting on more health plans, getting on more government health plans, including those can be very helpful, in just broadening your access to different patient populations.

One of the things as an individual physician, I'm on clinical faculty at UT Southwestern. We, go to Parkland Hospital which is predominantly serving underserved patients. And we teach the medical students, residents and allergy fellows in training. Most of the patients there are underserved, so that's helpful. So I encourage physicians to actually try to do that, in addition, really, it's a great educational opportunity, for us and for the trainees. And then we can help train different medical students, residents, fellows on dermatological conditions, and patients of color, and also underserved patients.

Host: Great. Thank you. And I know that the ACAAI has a designated webpage for patient information on eczema, at least in Spanish, which is a helpful resource for providers. And so we'll definitely link to that also. And then, really, I just want to have any final thoughts that either one of you have on this really important topic.

Dr. Nanda: I think learning from other physicians like we're doing today and Dr. Alexis and I we're in different specialties, right, dermatology, allergy immunology. But, you know, I learned a lot from my dermatology colleagues like Dr. Alexis and seeing their approaches to atopic dermatitis and he learns from us allergist immunologist about our approaches.

Dr. Alexis: I completely agree with your comments, Dr. Nanda, and I think, as a dermatologist, I can speak for my colleagues in dermatology; historically, you know, we focused on the skin manifestations of atopic dermatitis based on our area of expertise, but more and more we're collaborating with our allergy and immunology colleagues, as we recognize that this is atopic diseases, need to be managed in a multidisciplinary way, in many cases.

And so there are effects far beyond the skin. So, continued collaboration with our allergists and immunology colleagues with continued additions to our therapeutic armamentarium. I think we're in a better position to deliver better care and help our patients manage this long-term condition, atopic dermatitis in ways far better than in the past. And so I think the future is looking lot brighter.

Host: That's wonderful. And then finally, we're going to end with our patient voice Mackenzie, because I think we learn always more from our patients than anyone else. And so I just wanted to end this entire three series with her voice.

1: I would maybe say. When treating patients for eczema, not to only look at medication options but to also look at different holistic options,

for them as well, just because it's not just medication that does help or treat eczema. It's really just a whole rounded factor, because like you said, Everything else can help trigger those exit spots and make it even worse. and so just even looking at it from treating it from not just medical solutions, but also like whether or not a patient. May need to go to therapy or what their exercise, or eating habits look like, or even just what kind of temperature showers they're taking, Whether that's hot or cold showers. and that also has an effect on it. And then if they are treating. Patients of color like even looking at the medications that they're prescribing to them and seeing if those do have skin discoloration effect on that. And that's all the time we have. Thank you, to our guests. thank you to McKenzie for being our patient voice and thank you to you listeners for joining us. That concludes three of our three part series on Moving Towards Equity; Disparities in Atopic ermatitis from the ACAAI. For more resources around atopic dermatitis, visit https://education acaai.org/disparity. For other interesting episodes from Allergy Talk, please visit college.acaai.org/allergytalk. To receive CME credit for this or other eligible Allergy Talk podcasts visit education.acaai.org/allergytalk.

Host: And I'm Dr. Payel Gupta for the American College of Allergy Asthma and Immunology.