Kristen Demundo, PharmD, and Shannon M. Rotolo, PharmD, BCPS, review the important role pharmacists play in helping patients manage their atopic dermatitis condition and treatment.
Peter Lio, MD: Let’s focus on the role of the pharmacist in treating atopic dermatitis, something really important. Kristen, I’d like you to start us off and I’d like to ask you the question, how often do patients approach you for recommendations regarding over-the-counter treatments for atopic dermatitis?
Kristen Demundo, PharmD: It’s actually quite often, and more often than not I see pediatric patients more than adults, just because of the prevalence in that population. It can develop on any area of your skin at any age, but at certain ages it’s more common to appear on certain areas of the body. In infants, I see it more commonly on the faces, especially on the cheeks and also on the scalp it can occur. In children, it’s more commonly in folds and creases, behind the knees, elbows. It can be as Jamie touched on earlier, feet and also some areas of the trunk. In adults rather than rash, they present more with itchy, dry, irritated, and sensitive skin. In recent times, I’ve seen an exponential number of cases on the hands, hand eczema from the overuse of hand sanitizers and excessive handwashing. That has been definitely more of a concern for a lot of patients.
As pharmacists, we’re often the first line that a patient will come to before going to the doctor. They want to try something over the counter initially to see if that will resolve their symptoms. I see a higher number of patients present during certain times of the year. Allergy season can trigger it more, more so in winter and summer months with the extreme temperature changes. Patients usually present having a red itchy rash and aren’t always sure if it’s something allergy related that they’ve encountered from using a new detergent, or soap, or even something simple like heat rash.
Oftentimes, I will consult over the phone with them, and they can complain of dry, sensitive, irritated skin with a pruritic rash. Questions that I always pose to them initially are: Have you tried something new? Trying to rule out other factors and if they were exposed to something else other than it being atopic dermatitis...I also ask what they’ve tried previously and if it’s brought any relief, so I can narrow down a selection for therapy for them. Concerns that arise from the patients are most importantly, as you said earlier, how quickly they’re going to obtain relief. They are often very uncomfortable, and they want it healed almost immediately. They want relief and comfort, and they’re at the point where they’re seeking help and they want it to work quickly and, of course, safely.
Peter Lio, MD: Thank you. Speaking of safety, what concerns do they bring up with you or what are their worries or their fears about some of the medicines?
Kristen Demundo, PharmD: A lot of them are concerned especially with children. They want to make sure it’s safe and that it won’t affect or irritate the skin further because a lot of the skin is thin and fragile. They can be on sensitive areas, and they’re concerned about absorption and the safety of that, if it would have any side effects on it, if it would further irritate the skin. That’s a common concern of a lot of patients—just safety and “My skin already hurts so much and it’s so irritated.” Is this cream going to further irritate it or is it going to provide that relief that they’re looking for?
Peter Lio, MD: Such important stuff. Shannon, can you take us through a little bit and continuing this discussion about when you’re asked, as a pharmacist, what is the best over-the-counter therapy, how you can help direct people to select it? Also, recognizing when over-the-counter therapies are either not enough or not appropriate for those patients, how do you counsel and guide them?
Shannon M. Rotolo, PharmD, BCPS: Over-the-counter therapies, we certainly do have limited options. Of course, there are moisturizers, emollients, but, in terms of over-the-counter steroid options, we really don’t have that many. We’ve got hydrocortisone in a couple of different strengths and different formulations in creams and ointments. For patients where a trial of that therapy is not effective, we will need to be referring them on to whether that’s their pediatrician or a dermatologist. There may be a need for a step up from there. Most patients will need things like moisturizers or emollients, and perhaps for some patients, the over-the-counter steroid creams are going to be sufficient. If it’s not helping after an initial trial of therapy, then it really is time to refer.
Other times when you really want to get someone else involved, as a pharmacist, I don’t want to be making the call on is this also a bacterial infection. Anything that might suggest that there is an overlying bacterial infection happening here, that’s going to be a referral to their pediatrician, primary care person, or to a dermatologist. The things that pharmacists really can do for patients is providing good, solid education on how to apply medications.
A common thing that comes up with these is applying a pea-sized amount or that idea, that means really different things to different people. There’s some good studies about fluoride toothpastes about whether or not people know what a pea-sized amount means. The answer is we don’t, and a majority of parents will over dispense if you ask them to do a pea-sized amount of something, that amount is just wildly variable. While you’re going to get a closer result to the dose you intended probably by suggesting a pea-sized amount than just saying use a normal amount, it’s key that pharmacists educate on what an appropriate application is of some of these products, whether that’s a very thin layer for steroids of perhaps a more generous layer for some of those moisturizers or emollients.
Then assessing perceived understanding. Perhaps someone is coming to the pharmacy looking for that over-the-counter product after already having a discussion with their pediatrician or with a dermatologist. This isn’t being done as a prescription either because of insurance coverage barriers or they’re just quickly picking up something over the counter. We know from studies with pediatric patients using liquid medications, that a majority of caregivers will say, “Yes. I do understand the instructions for this.” But if you have them measure it with a syringe, only about two-thirds can demonstrate that they can measure that out. While it’s not studied as robustly, we do see similar things with topical products, as I was referring to the toothpaste. Making sure that individuals, parents, caregivers are clear on what the descriptors are for how much they should be applying, whether that’s a very thin layer, just enough to cover the area, or whatever is appropriate for that specific drug.
That’s really one of the key things that we can do in that setting and then also providing support around adherence. For children with moderate to severe atopic dermatitis, the average parent or caregiver is going to spend 3 hours a day on skincare. That is a lot of time. Providing that education and that reinforcement because we know that based on how demanding those regimens can be, we see a drop off from, in early weeks of therapy, about 80% adherence to less than 30% adherence by week 8. That makes sense with how demanding this can be. Again, making referrals if that’s something that folks are struggling with and just maybe need a therapy to provide a little better control of disease, so that that daily routine is a little less strenuous once they’ve achieved better control and monitoring for possible drug interactions or contraindications as they do escalate on therapy.
Peter Lio, MD: Thank you. That is incredibly thorough and just wonderful, listing some of the important roles the pharmacist can play and how critical that interaction is.
This transcript has been edited for clarity.