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Advancing Atopic Dermatitis Care: Assessing Disease Severity and Employing Shared Decision-making
CME/CE Information

Activity

Progress
1 2 3
Course Completed
Activity Information

Physician Assistants/Physician Associates: 0.25 AAPA Category 1 CME credit

Nurse Practitioners/Nurses: 0.25 Nursing contact hour

Physicians: maximum of 0.25 AMA PRA Category 1 Credit™

Released: July 03, 2025

Expiration: July 02, 2026

Benjamin Ungar
Benjamin Ungar, MD

Assessing Treatment Response in Moderate to Severe Atopic Dermatitis 

 

Okay. We will begin the first section, which is assessing treatment responses in moderate to severe atopic dermatitis. Just as a reminder, if you do have questions as they come up, please enter it in the Q&A and then we will have a chance at the end to discuss further.

 

[00:22:57]

 

Let’s Consider a Patient Case 

 

With that in mind, let us consider a patient case.

 

[00:23:01]

 

Patient Case 1: Julie, 52 Yr Old

 

We have Julie, who is a 52-year-old presenting with very dry skin, worsens in the winter, particularly when washing hands. The worsening dryness and itch that it involves a much of the upper torso, head and neck. She also has a history of obesity and asthma, and is currently being treated with topical corticosteroids, has had several courses of oral steroids and emollients. Has tried phototherapy without much improvement.

 

The question here is how would we assess the AD severity?

 

[00:23:34]

 

Clinical Assessment Tools  

 

There are several tools that can be used. From a practical perspective, when thinking about getting approval for people who meet these criteria, it is often beneficial to include more than one because insurance companies often will be looking for that. But that aside, some of the most commonly used tools are EASI score, Eczema Area and Severity Index, although I will say that is most commonly used in clinical trials because as we can see here, it takes a bit of time to implement it unless you have a very efficient workflow.

 

There is the Investigator Global Assessment, or IGA, which is separated out into five categories. That is a little quicker to implement. Of course, all these are variable, but often insurance companies will accept that as a measure of severity. There is SCORing Atopic Dermatitis, or SCORAD, which is more akin to EASI in terms of the complexity and use in clinical trials more than routine clinical practice.

 

Then there is also the Patient-Oriented Eczema Measure, or POEM, which can be a very helpful tool because it is eliciting patient-reported outcomes, not just the objective view that the physician or investigator would be looking at.

 

[00:24:43]

 

Atopic Dermatitis Control Tool: ADCT

 

There is also this Atopic Dermatitis Control Tool, or ADCT, which can be a useful tool as well. It is pretty quick to administer six questions to evaluate different dimensions of AD control. These are ones that have been identified as relevant by both patients and healthcare professionals. Either your patients can do it. It can be done in the office, and in many respects helps to have that conversation with patients to understand, okay, are you in a position where you are in that moderate range, then maybe a strong consideration for systemic therapy.

 

[00:25:22]

 

ADCT Measurements  

 

This is what the ADCT looks like in terms of the scoring. The goal here, of course, is that we want patients with AD to be well controlled. It is one thing to ask, “Hey, how is it doing?” But this is a more quantified rigorous in many respects tool to do that. As you can see here, if the score is greater than equal to seven may not be well controlled.

 

If in the shaded boxes there is more than one answer that is in that area, again, probably not well controlled. If it is worsening, increasing by at least five points, these are all indications that probably the patient may benefit from advancing therapy.

 

Okay. With Julie, on review of systems, she is irritated and anxious having sleep disturbance, which we know has many downstream negative impacts on really every aspect of my life. Occasional wheezing, persistent itch and dry skin. On physical exam, she has generalized cirrhosis, eczema on the face, head, hands, SCORAD of 18, ADCT of 17.

 

At this point, we know that she has had topical. She has tried phototherapy unsuccessfully, has been treated with multiple courses of oral steroids, suggesting that she is bad. Then after maybe initial improvement, she is flaring again. To me, this looks like someone who really is not well controlled for a number of reasons, and it is time to discuss whether it makes sense to advance therapy.

 

[00:26:57]

 

Shared Decision-making in AD  

 

Now, I think it is very important and something that probably all of us put into practice, but nevertheless, I think it is helpful actually to think about it in more structured terms, that is shared decision making in AD.

 

Now, of course, it is rarely the case that we tell a patient paternalistic, okay, this is the treatment that is going to work. But I think that there is that conversation framing different treatment options for patients that need to be thought about. One of the reasons for that is this is a chronic condition, and if the patient is invested in the decision, feels like they have taken a role in identifying the right treatment for them, they are much more likely to be adherent to follow up and really ultimately to have success.

 

The mechanism of shared decision-making really helps identify the best path forward with that. That includes patient preferences, patient goals. It may include logistical considerations. For some people phototherapy may not be an option because there is just no way to fit it into their lives, whereas an injection that happens every few weeks actually may be a perfect fit. I think it is hard to overstate the importance of this leading to good outcomes with patients.

 

[00:28:17]

 

Resources to Facilitate Shared Decision-making  

 

There are, of course, resources to help with this, maybe ones that are employed in the office that generally make sense I think, the idea of having a supportive environment, naturally, if you are in an office or a department that values this and supports it, it does make it easier.

 

We know that when it comes to systemic therapies, it is a team effort. It is very difficult for the prescribing physician or nurse practitioner or physician assistant to be the one dealing with everything. But when there is staff to help with paperwork, pharmacist to discuss, different aspects about the medications, psychosocial support, these can all be very important and helpful in achieving, I would say, good shared decision-making. That extends to all the clinical staff.

 

There are also tools that can help educate patients, which gives them a better position to make the decision. For example, the National Eczema Association has this EczemaWise tool that puts information into accessible terms for patients. That can be something to think about referring patients to as they are considering treatment options.

 

[00:29:28]

 

Employing Motivational Interviewing  

 

The conversation with patients. I think many of us learned about this in training and I think we all aspire to actually implement these ideas. But again, that does not hurt to take a step back and ask ourselves how much are we putting this into action, particularly since often it is a very busy practice and someone walks in with severe eczema and we already know in our minds, this person is very severe. He is not responding to treatments. We have to change the treatment approach.

 

But in order to do that, again, the patient needs to be convinced, needs to buy into it. Eliciting, evoking the patient's perspectives, what is bothering you? Tell me more about your experience? What do you think about these options? What questions do you have? That can help hone in on potential stumbling blocks, sticking points, and ultimately help guide the patient to a treatment that will help them.