Atopic dermatitis (AD) is a chronic inflammatory skin condition that can be particularly difficult to manage in some patients. Recently, a series of case-based discussions have shed light on the complexities of treating severe and refractory cases of AD. These discussions highlight the importance of individualized treatment plans and the need for a multidisciplinary approach to address the various aspects of the disease.
Case 1:
Adolescent Female with Severe Itch Impacting Sleep
A 12-year-old girl presented with an intensely itchy rash primarily in the bilateral antecubital and popliteal fossae. She had a history of AD since birth, which had recently begun to affect her sleep and social interactions. Clinically, she exhibited patches and plaques in the affected areas, with excoriation and yellow crusts, covering about 8% of her body surface area (BSA) with moderate inflammation.
Diagnosis Considerations:
The panel emphasized the importance of a broad differential diagnosis, especially in patients with skin of color where diseases may manifest differently.
Biopsies were considered when standard treatments were ineffective.
Treatment Approach:
Previous therapies had not fully worked, prompting consideration of newer treatments like ruxolitinib cream, which provided rapid itch relief.
The panel discussed the potential benefits and risks, ultimately deciding to proceed based on supporting research showing no adverse events in similar patients.
Case 2:
A 36-year-old man with a history of AD since childhood experienced a flare-up on his trunk and arms after moving to a dusty apartment. Despite using corticosteroids, his AD remained uncontrolled, significantly affecting his quality of life.
Treatment Factors:
The patient’s history of depression and childhood asthma added complexity to his treatment plan.
The panel emphasized the need for a collaborative approach, involving psychologists or psychiatrists to address the broader impact of eczema on his mental health.
Comorbidity Concerns:
The panel noted that therapies should address both his skin and respiratory issues if asthma was still a concern.
The patient’s history of depression warranted careful consideration to avoid treatments that could exacerbate his mental health.
Outcome:
The patient initially improved with ruxolitinib but struggled with regular use, leading to consideration of oral or injectable therapies.He ultimately opted for dupilumab, which significantly improved his condition after three months.
Conclusion
These cases underscore the challenges in managing severe and refractory AD. They highlight the need for individualized treatment plans that consider the patient’s medical history, comorbidities, and preferences. A multidisciplinary approach, involving dermatologists, allergists, and mental health professionals, is crucial for improving patient outcomes and quality of life.
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