Does atopic dermatitis always start in childhood?

You. My experience is that the vast majority of adults with atopic dermatitis have adult onset atopic dermatitis. Now, I was trained in residency that atopic dermatitis always starts in childhood, is always flexural, and is always associated with strong personal history of atopy. None of those things are true. Whenever you look at the AAD census criteria, which I think are fantastic. It's itchy, it's chronic, it's spongiotic, it spares the groin and axilla if it has those four characteristics, and it's not allergic contact dermatitis, it's not scabies, it's not sebraic dermatitis, it's not psoriasis, it's not any of those other things that we can easily rule out. So really, it becomes that atopic dermatitis is your default diagnosis for everyone with spongiotic dermatitis, unless it involves a groin and axilla or you are certain that there's some other type of dermatitis. So, again, does it always start in childhood? No. And in fact, my experience is, in adults, the vast majority of people who meet the criteria had no history of childhood dermatitis at all. In a purely adult onset disease.

Navigating Patient Conversations

The following are opinions of Dr. Tina Bhutani and are not intended to replace the informed consent process between a doctor and patient, nor is it intended to serve as medical and or legal advice. This video is not intended to replace all of the REMS requirements. More information will be discussed later in this video. Hello, I'm Tina Bhutani, the co director of the UCSF Psoriasis and Skin Treatment center and the UCSF Dermatology Clinical Research unit director. I work at a tertiary referral center at a university, so patients come to me after they have tried and failed biologics. I rarely see patients who are biologic naive for the adult patient who has tough to treat psoriasis and has already tried one, two, now even sometimes three biologics. By the time they come into my office, I think about Siliq I am a certified Siliq prescriber. I'm here today to talk to you about an important conversation you should have about suicidal ideation and behavior with patients you're considering prescribing Siliq for, and to take the mystery out of that worthwhile and simple conversation. Siliq is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond to or have lost response to other systemic therapies. Patients who come to me with tough to treat psoriasis have usually failed other biologics and don't really think there's much hope of finding a treatment that may work for them and that can really take a toll on them. We know that unfortunately, patients with psoriasis are more likely to be diagnosed with mental health disorders such as depression and anxiety, so we should be talking to them about this. I bring this up because to put patients on Siliq, you have to follow the Siliq risk evaluation and mitigation strategy, or REMS program. The reason for this is during the clinical trials for Siliq, there were some patients who had suicidal thoughts and unfortunately, a few who also died by suicide. While we don't think this is unique to Siliq, it's important to inform your patients about it. And remember, patients with a history of depression can still use siliq as long as their depression is controlled. However, there is a boxed warning for suicidal ideation behavior. Today I will cover how I discuss important safety information about Siliq, including the boxed warning and the REMS program with my patients who are first starting Siliq. My REMS conversation is fairly easy and it typically takes about three minutes I start off with what to expect in terms of efficacy and safety, and then tell them you're going to notice there's a warning about suicidal ideation and behavior. We know that patients with psoriasis are more likely to be diagnosed with depression. In line with that during the clinical trials. Sadly, four patients out of 4400 committed suicide because of this warning. We're going to talk about it today and go through some paperwork and have you sign off on the REMS program. I'll pull out the paper form from the drawer and walk through the form step by step. The forms are quick and easy. I will talk about suicidal ideation and behavior and the fact that it's a comorbidity of psoriasis. I explained to them, I want you to be very aware of your mood, and should you notice any new or worsening depression or any depressed thoughts whatsoever, or if you have any thoughts of hurting yourself, I want you to get in touch with me as quickly as possible. If you can't get in touch with me, we're going to give you this card that has the phone number for the National Suicide Prevention hotline. I want you to keep this card in your wallet at all times, and I want you to call this number and seek immediate attention should you have any issues while you're taking this drug. I also want you to ask people around you to let you know if they notice you're becoming depressed, because sometimes you're not aware of your mood changes, but others around you might be. At the end of the discussion, the patient signs the form, and my office staff will fax it. And that's really it. That's how I make sure I'm following the sale REMS program requirement. The paper forms for us are quick and easy. While I typically stick to the paper process, the electronic component is available and does a good job. Electronic forms would save my office the time of faxing in the form. Even though it doesn't take that long, some REMS programs can seem very burdensome and time consuming. The Siliq REMS program is not like this. It's super quick and easy to not only register yourself as a rems provider, but also to get your patients signed up for the first time, you prescribe siliq. When patients come to me, they're tired and have seen a ton of doctors. They don't really think anything will help them, but they still want to talk about it. I've had so many of these patients put on Siliq, and they're responding, which is a great thing. We know that areas like the scalp, the palms, and the soles are tougher to treat. I've had great experiences using siliq with many patients in the past. There's a case of two brothers with terrible, tough to treat psoriasis. They had tried and failed cyclosporin, methotrexate, and all the biologics. We put them on Siliq and they responded. Even today, they're still clear. Generally, by the three month point, we see a lot of clinical improvement for these patients. Solique has helped so many of my patients, and having these brief rems conversations saves a lot of time in the long run. You're documenting exactly the conversation that you're having, and it has the patient's signature right there on it. A REMS program ensures that the patient and the doctor have a full conversation versus when we're prescribing many other biologics, it is important to talk about it in our practice. We should be encouraging these types of conversations because for our patients, having psoriasis can be tough as it is now. Before we close, I want to be sure you get a chance to hear some additional information about the Siliq REMS program and important safety information for SiLIQ. The Siliq REMS program physicians must register for the Siliq REmS program@salerems.com. Discontinuation or transfer of care must be reported to the Siliq REMS program. This video is not intended to replace all of the REMS requirements. Complete details about the SiLIQ rems are available@salikrems.com. Indication SilIQ injection is indicated for the treatment of moderate to severe plaque psoriasis in adult patients who are candidates for systemic therapy or phototherapy and have failed to respond or have lost response to other systemic therapies. Important safety information warning suicidal ideation and behavior suicidal ideation and behavior, including completed suicides, have occurred in patients treated with Siliq. Prior to prescribing SilIq, weigh the potential risks and benefits in patients with a history of depression and or suicidal ideation or behavior. Patients with new or worsening suicidal ideation and behavior should be referred to a mental health professional as appropriate. Advise patients and caregivers to seek medical attention for manifestations of suicidal ideation or behavior, new onset or worsening depression, anxiety, or other mood changes. See warnings and precautions in the full prescribing information. Because of the observed suicidal behavior in subjects treated with SiLIQ, SiLIQ is available only through a restricted program under a risk evaluation and mitigation strategy rems, called the Siliq REMS program. See warnings and precautions in the full prescribing information. Crohn's disease Siliq is contraindicated in patients with Crohn's disease. In clinical trials, which excluded Crohn's patients, one Siliq patient was withdrawn after developing Crohn's disease. Discontinue Siliq if a patient develops Crohn's disease. Siliq risk evaluation and mitigation strategy REMS program Siliq is available only through a restricted program called the sale rems because of observed suicidal ideation and behavior in patients treated with Siliq. Before prescribing Siliq, prescribers must be certified with the program. Have each patient sign a patient prescriber agreement form and provide the patient a wallet card describing symptoms requiring immediate medical evaluation. Pharmacies must be certified and only dispensed to patients authorized to receive SiLIQ. More information is available@saliquerems.com or by calling the Salik REMS program call center at 855-11-6135 infections SiLIQ may increase the risk of infections serious infections and fungal infections were observed at a higher rate in patients treated with SiLIQ than placebotreated patients in clinical trials, including one case of cryptococcal meningitis that led to discontinuation of therapy. Consider risks and benefits prior to prescribing SiLIQ in patients with a chronic infection or history of recurrent infection. Instruct patients to seek treatment if signs or symptoms of a chronic or acute infection occur. Risk for latent tuberculosis TB reactivation evaluate patients for TB prior to initiating treatment with SiliQ and do not treat patients with active TB. Initiate treatment for latent TB prior to starting SilIQ and consider anti TB therapy prior to initiation in patients with history of latent TB if adequate treatment cannot be confirmed. Monitor closely for symptoms of active TB during and after treatment immunizations avoid use of live vaccines in patients treated with Siliq. Adverse reactions the most commonly reported adverse reactions in clinical trials were arthralgia, headache, fatigue, diarrhea, oropharyngeal pain, nausea, myalgia, injection site reactions, influenza, neutropenia, and tinia infections. To report suspected adverse reactions, contact Bauch Health at 1803 214576 or the FDA at 1800 FDA 1088 or visit FDA Gov medwatch. Please see full prescribing information, including boxed warning about suicidal ideation and behavior@salique.com.

<p>Watch as Tina Bhutani, MD, explains how she discusses an important topic with her patients being treated for moderate-to-severe plaque psoriasis who participate in the REMS program. Dr. Bhutani describes how she structures the patient conversation about the program, the importance of discussing the mental health comorbidities of psoriasis, and how she advises patients on what to do if they notice changes in mood or symptoms of depression. She also describes the simple process of navigating and submitting the REMS program forms.</p>

What are some common triggers for worsening of atopic dermatitis?

You. It's amazing. The more patients I meet, the more I realize that there is an entire universe of different things that can cause people to have a flare up, from extreme cold weather to extreme hot weather, to sweating and not washing that off quickly enough to, of course, cats and dogs and other pets, certain fabrics like wool, all of these things. But even things like stress, psychological stress, lack of leap, all of these things can push people towards a flare up. And many of my patients come initially saying, can we try to find the things that are causing a flare up, those triggering events? But after a while, I usually try to sort of allay those concerns, because what we find is there's so many things that could do it. At some point, the only solution would be to be in a bubble or move to the moon, and that's just not going to be something most people can or would want to do, frankly. So what I say is, I turn that around and say there are many, many triggers, and of course, we want to try to find the ones that are easy to find. And we may even do special testing, for example, in the case of somebody that may have either a food exacerbated ad or more commonly, a contact dermatitis, an allergic contact dermatitis that can be triggering their skin as well. We can do specialized testing, but generally speaking, my hope is to get them better, strengthen their skin barrier, and cool the inflammation. If for no other reason than that helps us kind of cut the wheat from the chaff, we can then say, okay, those other things you thought, now you're okay, they're not bothering you, maybe these top two or three things, these still seem to be causing a flare up, and that will really help us know what's going on.

Do contact dermatitis and atopic dermatitis commonly co-exist?

You. So this is a really interesting question about the overlap between contact dermatitis and atopic dermatitis. There are some studies that say contact derma is more common in atopics, some studies that say it's less common. Some studies say there are certain allergens that are overrepresented, other studies that say there are not. My personal opinion and experience is that contact dermatitis in patients with atopic dermatitis is the same frequency as it is in everybody else. So the increased penetration and exposure to allergens through atopic skin is basically offset by the fact that they're predisposed to th two activity rather than th one activity. And I think it ends up being a wash. So they're no more or less likely to have contact derm than is anybody else. The big thing is that you see somebody with atopic derm that is not acting the way that it ought to. It's not responding to topical therapy. Or you see somebody who treat them for atopic derma, they only get partially better. Those are people who you should really think, is there a combination contact dermatitis and atopic dermatitis? Do I have to treat both in this patient?

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