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Case Nº 054 · Dr. Aaron Wong

EC2Change Case FileAtopic dermatitis

054

A 37-year-old male with moderate disease

  • Skin of colour
  • Special sites: hands, head, neck, genitals

Case byDr. Aaron Wong

1 follow-up visit
1 photograph

At a glanceCase Nº 054

At a glance

A 37-year-old male, moderate atopic dermatitis

ScoreBaselineLatest visit
EASI215
BSA20%5%
Itch NRS81
IGA3—

In this file

1
The patientCase Nº 054

37

The patient

year-old male,
moderate disease

  • Skin of colour
  • Special-site involvement

Special sites involved: Hands, Head, Neck, Genitals

Race / ethnicity

Asian

Fitzpatrick skin type

5

Previous diagnoses

Atopic dermatitis - longstanding

Comorbidities & context

Asthma, Allergic rhinoconjunctivitis (hayfever), Depression / anxiety Prior alopecia areata (now stable)
2
Treatment historyCase Nº 054

Treatment history

What came before

Treatment at presentation

Triamcinolone acetonide 0.1% cream (Aristocort-R, Triaderm, Ratio-Triamcinolone, 500 g jar) twice daily to body Desonide cream (60 g)- face & folds BID prn Mometasone 0.1% lotion (60 ml)- scalp BID prn Ruxolitinib 1.5% cream - in process

3
Treatment historyCase Nº 054

Treatment history

What came before, continued

Previous topical therapy

Tacrolimus 0.1% ointment Pimecrolimus 1% cream Crisaborole 2% ointment Roflumilast 0.3% cream From GP: terbinafine 1% cream, betamethasone dipropionate 0.05% / clotrimazole cream, and DovoBET gel

Previous other therapy

Phototherapy - not effective & now accessible due to work
4
Disease assessmentCase Nº 054

Disease assessment

Severity at baseline

EASI

Eczema Area and Severity Index

21of 72

BSA

Body surface area

20%of 100%

Itch NRS

Peak pruritus numerical rating scale

8of 10

IGA

Investigator's Global Assessment

3of 4

5
Disease assessmentCase Nº 054

Disease assessment

On the skin

Erythema

  • Violaceous
  • Blue-gray

Site: Neck, eyelids

Thickness

  • Papulation
  • Follicular

Site: Face, neck, back & chest, antecubital fossa, popliteal fossa Follicular prominence of thighs, legs / forearms

Lichenification

  • Nodules
  • Furrowing

Site: forehead, hands & neck

6
Disease assessmentCase Nº 054

Disease assessment

On the skin, continued

Excoriation

  • Bleeding

Pigmentary changes

  • Post-inflammatory hypopigmentation
  • Post-inflammatory hyperpigmentation
7
Disease assessmentCase Nº 054

Disease assessment

How it shaped care

Impact on diagnosis

Neck, face & hands

Impact on treatment selection

Trying to avoid topical corticosteroids around eyelids; ruxolitinib in process

Impact on treatment priorities

Reduce usage of steroids; improve appearance of skin, reduce pruritus, increase sleep
Less BSA, improved EASI,
Physician goals
8
Treatment selectionCase Nº 054

Treatment selection

The plan

Tralokinumab 600 mg SC at week 0 and then 300 mg SC q 2 weeks; tried to go q4 weeks for 2-3 months but patient noted increased itching by week 2-3

Treatment goals

Clearance Improved sleep & concentration at work Less itch Less discoloration to skin

What drove the choice

Patient was interested in a biologic Oral JAKi were discussed but had concerns re: black box warnings
9
Treatment selectionCase Nº 054

Treatment selection

The plan, continued

Safety concerns

Prolonged steroid use --> ocular complications or cutaneous atrophy

Target scores

EASI
21
from 21
BSA
20%
from 20%
Itch NRS
9
from 8
10
Follow-upCase Nº 054

Follow-up · visit 1 of 1

Under 6 months on treatment

Improved at month 3 and still doing well at month 11

EASI

Eczema Area and Severity Index

5of 72

−16 vs baseline of 21

BSA

Body surface area

5%of 100%

−15 vs baseline of 20

Itch NRS

Peak pruritus numerical rating scale

1of 10

−7 vs baseline of 8

11
Follow-upCase Nº 054

Follow-up · visit 1 of 1

Visit 1, continued

Lesions at this visit

Erythema
— Improved
Thickness
— Improved
Excoriation
— Less erythema, thickness & lichenification; lichenification is skin coloured and not as inflamed on forehead & hands but still present
Pigmentary changes
— Still has PIH (hyper & hypo); but improving

Symptoms & daily life

Pruritus
— Improved - NRS 2
Work impairment
— Improved sleep --> better focus & concentration at work
Impaired social function
— Able to see his friends and family more; has received indirect complimentary questions (eg. "What happened to you? What did you do for your skin?")
12
Follow-upCase Nº 054

Follow-up · visit 1 of 1

Visit 1, continued

Treatment plan

Treatment continued unchanged

  • Patient satisfied
13
Follow-upCase Nº 054

Visit 1 photographs

Neck plaques with red-purple hue, thickness and scale
14
OutcomesCase Nº 054

Outcomes

Scores over time

EASI030Target 21Baseline: EASI 2121V1: EASI 55BaselineV1BSA020Target 20%Baseline: BSA 20%20%V1: BSA 5%5%BaselineV1Itch NRS010Target 9Baseline: Itch NRS 88V1: Itch NRS 11BaselineV1

V = follow-up visit. Each scale starts at zero. Grey line = physician’s target.

15

A 37-year-old male with moderate atopic dermatitis.

EC2Change Case File Nº 054

Contributed by Dr. Aaron Wong. Compiled from the physician’s case-builder submission, in their own words.