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Case Nº 049 · Dr. Tetyana Khlabatyn

EC2Change Case FileAtopic dermatitis

049

A 66-year-old female with severe disease

  • Elderly
  • Advanced systemic failure
  • Special sites: head, neck
  • Prior JAK inhibitor failure

Case byDr. Tetyana Khlabatyn

2 follow-up visits

At a glanceCase Nº 049

At a glance

A 66-year-old female, severe atopic dermatitis

ScoreBaselineLatest visit
EASI31—
IGA3—
DLQI19—

In this file

1
The patientCase Nº 049

66

The patient

year-old female,
severe disease

  • Elderly
  • Special-site involvement
  • Advanced systemic failure

Special sites involved: Head, Neck

Previous diagnoses

new onset of generalized dermatitis with significant facial involvement history of recurrent hand dermatitis and childhood eczema

Comorbidities & context

ortho surgery in 6-8 weeks necessitating intervention
2
Treatment historyCase Nº 049

Treatment history

What came before

Treatment at presentation

failure of pimecrolimus (face), betaderm 0.05% (body), desonide (face and body) remote failure of light therapy

Previous topical therapy

pimecrolimus (face), betaderm 0.05% (body), desonide (face and body)

Previous systemic therapy

upadacitinib 15 mg PO OD
3
Treatment historyCase Nº 049

Treatment history

What came before, continued

Advanced systemics that failed

  • JAK inhibitorInadequate response
4
Disease assessmentCase Nº 049

Disease assessment

Severity at baseline

EASI

Eczema Area and Severity Index

31of 72

IGA

Investigator's Global Assessment

3of 4

DLQI

Dermatology Life Quality Index

19of 30

5
Disease assessmentCase Nº 049

Disease assessment

On the skin

Erythema

  • Red / pink

Thickness

  • Papulation

Lichenification

  • Furrowing

Excoriation

  • Bleeding
6
Disease assessmentCase Nº 049

Disease assessment

How it shaped care

Impact on diagnosis

significant cutaneous involvement - risk of hip replacement being cancelled

Impact on treatment selection

required something with rapid onset due to above
rapid onset, safety not a concern
Patient goals
7
Treatment selectionCase Nº 049

Treatment selection

The plan

upadacitinib 15 mg PO OD x 4 weeks given per patient request (not keen on prednisone or other JAKi, not enough time for biologics to achieve clearance in time for hip surgery)

Treatment goals

keen to get skin clear prior to ortho surgery to avoid cancellation

Safety concerns

safety not a concern for patient, felt hip pain was 100000 x worse than any black box warning
8
Treatment selectionCase Nº 049

Treatment selection

The plan, continued

Target scores

EASI
5
from 31
IGA
1
from 3
9
Follow-upCase Nº 049

Follow-up · visit 1 of 2

Under 6 months on treatment

Lesions at this visit

Erythema
— worsened
Thickness
— worsened
Lichenification
— worsened
Excoriation
— worsened

Symptoms & daily life

Pruritus
— severe effect on sleep
Impaired social function
— facial involvement interfered with social calendar
10
Follow-upCase Nº 049

Follow-up · visit 1 of 2

Visit 1, continued

Treatment plan

Treatment modified

Patient not satisfied
— Biopsy: “Spongiotic derm with rare eosinophils, focally psoriasiform. Spongiotic dermatosis (e.g. atopic dermatitis, contact dermatitis and nummular dermatitis is favoured. “ Incomplete clearance on Upadacitinib, not keen on 30 mg trial or other JAKi.
Modification made
— Adtralza started due to : - facial involvement - fear of Th2- Th1 switch with dupilumab o interestingly case reports of successful treatment with tralokinumab in patients with AD and dupi-induced psoriasis
11
Follow-upCase Nº 049

Follow-up · visit 2 of 2

Under 6 months on treatment

Lesions at this visit

Erythema
— reduced
Lichenification
— reduced

Symptoms & daily life

Pruritus
— resolved in 1 mo
Impaired social function
— 80 % facial resolution in one month on Adtralza

Treatment plan

Treatment continued unchanged

  • Physician satisfied
12

A 66-year-old female with severe atopic dermatitis.

EC2Change Case File Nº 049

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