As part of our desire to spotlight leaders in the field of dermatology, the following is the first of a two-part article on Peter Lio, MD, FAAD, an expert in Atopic Dermatitis. Dr. Lio is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine, and a physician with Medical Dermatology Associates of Chicago. A full bio of Dr. Lio follows the article. Look for Part 2 of this article next week.
dermRounds: Dr. Lio, we are excited to have you join us today as an expert in Atopic Dermatitis.
We would like to start off by learning how you developed an interest in Atopic Dermatitis. Were there specific experiences which drove you to pursue this area further?
Dr. Lio: I have long been interested in inflammatory skin conditions, and when I first started practicing in 2005 I realized that I had many tough cases of AD from the very start. I truly felt the burden of unmet needs in this area, especially as I watched our colleagues in Psoriasis undergo an incredible revolution with biologics. I kept thinking that severe AD is every bit as bad as psoriasis, and arguably worse for the patients as it adds in terrible intractable itch and frequent infections, both of which are far less common in psoriasis. When I joined the faculty at Northwestern, Dr. Amy Paller was very supportive of building this clinical interest and she was a mentor and an inspiration--and still is! --in AD.
dermRounds: Atopic Dermatitis is a condition that can require a good amount of counseling. Most dermatology visits tend to be short. How do you arrange your workflow to account for this need for counseling and education?
Dr. Lio: This is a tough question but really gets to the heart of the issue: part of the reason why this is so tough to treat is that there isn't a simple one- or two-line plan to boil things down... the approaches are often complex, multi-factorial, and the patients tend to be highly-educated and brimming with questions! I try to book new patients referred in for AD at the end of the morning or end of the day so that I have some buffer. I also try to have a very close follow up--sometimes just a week or two later--to give extra-close attention and to continue the discussion about "next steps". Some could caution that it looks like I'm padding my schedule or trying to "milk" the patients, and I suppose that the flag could get raised if a lot of visits were booked out at 1-2 weeks. However, my schedule is pretty full several months out, so this is not something I would do unless I felt it had real utility for the patient, and fortunately, after that visit if all is well, we can generally space out to 2-3 months, a more common follow up interval in dermatology. For better or for worse, I also do try to leverage technology with our patient portal (secure email) and phone triage whenever possible. Sometimes this adds a LOT of extra work and time that is uncompensated, and I do worry that this type of open communication disproportionately contributes to physician burnout.
dermRounds: Many of us have had experience with patients who are reluctant to use prescribed therapies such as topical steroids. How do you deal with these situations?
Dr. Lio: Topical steroid phobia is really tough because, for better or for worse, topical steroids are still pretty central to treating most AD. I think we all dream of the new agents that will totally replace steroids, but it is a very tall order given their known side effects/safety balance, their effectiveness, and their relatively low price to new agents. That said, I try my hardest to avoid and/or minimize their use whenever possible and I make it a key part of the visit to talk about how our goal is to be tapering use over time. For those who keep escalating use, I am a strong proponent to move to other approaches, everything from phototherapy, non-steroidals, systemic agents, and even sending a patient to one of the medical balneotherapy treatment spas in France last year for an intensive treatment period in a specialized setting.
dermRounds: There have been a number of new medications on the market for Atopic Dermatitis, namely Eucrisa and Dupixent (dupilumab). Can you take us through how you have practically been using these? How are you selecting your patients? What is the youngest patient that you have used Dupixent for?
Dr. Lio: My interest in AD happened in a time when there was almost no "pipeline" for AD products... and now finally, I feel like we've won the lottery with many new agents being developed and even coming to market. Crisaborole and dupilumab are two new and very different treatments that have come out in the past 2 years, and I am grateful for the first new FDA-approved drugs for AD since pimecrolimus!
They have very different indications and I use them quite differently. For crisaborole (a topical non-steroidal that targets PDE4-mediated inflammation), I use it in mild or moderate cases, especially in areas where steroids are not safe using for long periods, such as the face and neck, or flexural areas. My personal experience with this ointment is that it seems to be most helpful in patients after I cool down the initial inflammation with a topical corticosteroid, and then once better, they can use crisaborole to keep the areas clear. I find that it is a good fit for some of the patients, but the issues are three-fold: 1) It is expensive and insurance often denies it; 2) It can sting or burn when applied, particularly, in my experience, when it is applied to more inflamed or open/cracked skin, hence my using it as more of a maintenance; 3) Its anti-inflammatory effect is more modest than I hoped, and for some patients it is simply not strong enough to control their skin. I am at a particular bias here because I tend to see more severe patients that are often referred in for being refractory, and so it may be a better fit for those initial cases of mild-moderate AD that I don't get to see as often. Still, I am very grateful for the innovation, the option especially in those that do not want topical steroids, and the fact that it really can be used for much longer intervals than topical steroids and does not have the black-box warning like the topical calcineurin inhibitors.
For dupilumab, an injectable biologic that impedes IL-4 and IL-13 production, the FDA deemed it a "breakthrough" drug and I have to agree: it is the first systemic agent approved for moderate to severe atopic dermatitis! (Well, technically prednisone is approved for it, but that is not really a long-term option for most, and we try our best to avoid even short or infrequent systemic corticosteroids in chronic inflammatory dermatoses.) I have found that some 80% of my patients--those who were at least moderate and often severe and fairly miserable, most having been on cyclosporine (off-label of course) or methotrexate (off-label) or mycophenolate (off-label)--have gotten to the point of being incredibly happy with their improvement. This has been a life-changing drug for many. It is not all rainbows and sunshine however, as there are several issues: 1) It is expensive, less so than many psoriasis biologics, but orders of magnitude more than topical care; 2) It is currently only approved in adults, aged 18 and up, making it out of reach for most younger patients where there is still a great deal of need; 3) There are some side effects including a drug-related conjunctivitis that happens in about 10% of patients; 4) It is an injection which makes it less palatable for some. That said, it marks the beginning of new systemic approaches to AD and new understanding of disease, for which I am grateful.
dermRounds: What are some go-to tips you have picked up over the years for treating complex atopic dermatitis cases?
Dr. Lio: One of my favorite tips is that if a patient finds that moisturizers make the skin feel hot and sweaty, you can have them keep it in the refrigerator (not the freezer), as it will make it feel cool and soothing when applied to the skin. There is evidence that the cooling effect itself also has some direct anti-inflammatory and anti-itch effects, which can be a nice multiplier for inflamed skin!
Another tip in a tough case is to try to carve out a few minutes in the office to actually apply the medications or moisturizers to the patient. With samples, you can do this to show them: how much to put on (frequently patients underuse the topical steroids due to fear), to ensure that things will not sting (a pro-tip for kids who say, "everything burns!"), and I think it is a powerful psychological and inspirational act that makes an impact on the patients. I remember once an 11-year old girl who had severe oozing and crusting at the wrists and said that everything burned, I applied an Unna boot wrap to the wrist and she started sobbing... I said: "What's wrong, does it hurt?" And she said: "No, I'm crying because I know it's going to get better now!" We are often in such a rush, we sometimes don't even touch the patient, and actually using our hands to apply a medication or moisturizer is a powerful act.
Peter Lio, MD, FAAD is a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine. Dr. Lio received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, he received formal training in acupuncture. Dr. Lio served as a full-time faculty at Harvard (Beth Israel & Children’s Hospital Boston) from 2005-2008 before returning to his native Chicago to join Northwestern and Lurie Children's Hospital. Dr. Lio is the founding director of the Chicago Integrative Eczema Center and has spoken nationally and internationally about eczema and atopic dermatitis, as well as alternative medicine. He remains active in clinical research, serves as a section editor for the Archives of Diseases in Childhood, and has published two textbooks and over 100 papers in the peer-reviewed literature. He has received a Leader of Distinction Award, a Presidential Citation from the American Academy of Dermatology, and numerous teaching awards. He currently serves as a board member and scientific advisory committee member for the National Eczema Association.
Disclosure: Dr. Lio has served as a consultant/advisor and speaker for Regeneron, Sanofi Genzyme, Anancor, and Pfizer.