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Case Nº 056 · Dr. Tiffany Chen

EC2Change Case FileAtopic dermatitis

056

A 19-year-old male with moderate disease

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

Case byDr. Tiffany Chen

4 follow-up visits
1 photograph

At a glanceCase Nº 056

At a glance

A 19-year-old male, moderate atopic dermatitis

ScoreBaselineLatest visit
EASI127
BSA15%6%
IGA23

In this file

1
The patientCase Nº 056

19

The patient

year-old male,
moderate disease

  • Skin of colour
  • Special-site involvement

Special sites involved: Hands, Head, Neck

Race / ethnicity

Half Japanese, Half South Asian

Fitzpatrick skin type

IV

Previous diagnoses

Autism spectrum disorder Atopic dermatitis Seasonal allergies Acne
2
The patientCase Nº 056

The patient

The patient, continued

Comorbidities & context

ASD affecting patient's experience with atopic dermatitis: 1. Heightened sensory sensitivity 2. Communication and expression 3. Behavioral and repetitive patterns 4. Challenges with treatment adherence
3
Treatment historyCase Nº 056

Treatment history

What came before

Treatment at presentation

Protopic 0.1% ung Blexten for pruritus

Previous topical therapy

Hyderm cream (discontinued)

Previous systemic therapy

Blexten 20 mg tablets
4
Disease assessmentCase Nº 056

Disease assessment

Severity at baseline

EASI

Eczema Area and Severity Index

12of 72

BSA

Body surface area

15%of 100%

IGA

Investigator's Global Assessment

2of 4

5
Disease assessmentCase Nº 056

Disease assessment

On the skin

Erythema

  • Violaceous

Site: Periocular area, neck, antecubital fossae, popliteal fossae, hands Patient Half Japanese, Half South Asian

Excoriation

    Site: Neck

    Pigmentary changes

    • Post-inflammatory hyperpigmentation
    6
    Disease assessmentCase Nº 056

    Disease assessment

    How it shaped care

    Impact on diagnosis

    Mild to moderate atopic dermatitis

    Impact on severity rating

    Mild to moderate
    Family had recently moved to Burlington area from Japan
    Patient goals
    7
    Disease assessmentCase Nº 056

    Baseline photographs

    Mild dermatitis with lichenification and hyperpigmentation on neck
    8
    Treatment selectionCase Nº 056

    Treatment selection

    The plan

    Counseled on behavioural measures and importance of emollients. Reviewed need for regular use of topical therapies. Family opted to continue Protopic 0.1% ung and prescription provided for Elidel cream as well.

    Treatment goals

    Family initially expressed preference for topical therapies given recent relocation and situational triggers.
    9
    Treatment selectionCase Nº 056

    Treatment selection

    The plan, continued

    What drove the choice

    Reviewed treatment options including topical therapy, phototherapy, and systemic therapy. Family preferred to continue with topical therapy.

    Safety concerns

    Family requested non steroidal topical therapies.
    10
    Follow-upCase Nº 056

    Follow-up · visit 1 of 4

    Under 6 months on treatment

    4.5 months

    EASI

    Eczema Area and Severity Index

    17of 72

    +5 vs baseline of 12

    IGA

    Investigator's Global Assessment

    3of 4

    +1 vs baseline of 2

    Lesions at this visit

    Erythema
    — worse, more violaceous in colour
    Thickness
    — worse
    Lichenification
    — worse
    Excoriation
    — worse
    Pigmentary changes
    — worse
    11
    Follow-upCase Nº 056

    Follow-up · visit 1 of 4

    Visit 1, continued

    Symptoms & daily life

    Pruritus
    — Initial under-appreciation of severity of pruritus due to ASD and patient's difficulty expressing discomfort, pain, or describing symptoms accurately. Patient's father notes pruritus is interfering with sleep. Patient scratching throughout the night.
    12
    Follow-upCase Nº 056

    Follow-up · visit 1 of 4

    Visit 1, continued

    Treatment plan

    Treatment modified

    Patient not satisfied
    — response to topicals
    Physician not satisfied
    — response to topicals
    Modification made
    — Recognition from family of the challenges of long-term topical therapy in the setting of ASD Worsening burden of disease on visible areas such as face, neck, and hands Enrolment for tralokinumab
    13
    Follow-upCase Nº 056

    Follow-up · visit 2 of 4

    Under 6 months on treatment

    1 month

    Lesions at this visit

    Other
    — Virtual appointment just after initiation of tralokinumab

    Symptoms & daily life

    Pruritus
    — "Not scratching the same as before"

    Treatment plan

    Treatment continued unchanged

    • Patient satisfied
    • Physician satisfied
    14
    Follow-upCase Nº 056

    Follow-up · visit 3 of 4

    Under 6 months on treatment

    3 months

    EASI

    Eczema Area and Severity Index

    7of 72

    −5 vs baseline of 12

    BSA

    Body surface area

    6%of 100%

    −9 vs baseline of 15

    Lesions at this visit

    Erythema
    — Improved, some lingering faint erythema on cheeks, chin, hands
    Thickness
    — Improved
    Lichenification
    — Improved
    Excoriation
    — Improved
    Pigmentary changes
    — Improved
    15
    Follow-upCase Nº 056

    Follow-up · visit 3 of 4

    Visit 3, continued

    Symptoms & daily life

    Pruritus
    — Still flares with heat - after shower, there is an increased itch for a short time No longer needing Protopic as often

    Treatment plan

    Treatment continued unchanged

    • Patient satisfied
    • Physician satisfied
    16
    Follow-upCase Nº 056

    Follow-up · visit 4 of 4

    Under 6 months on treatment

    6 months

    Lesions at this visit

    Erythema
    — Limited to lower face
    Pigmentary changes
    — Less evident than at baseline
    Other
    — Patient affect improved

    Symptoms & daily life

    Pruritus
    — Continued improvement in pruritus as per family - no longer noting repetitive rubbing and scratching Family notes convenience of treatment regimen and less reliance on cumbersome topical applications
    17
    Follow-upCase Nº 056

    Follow-up · visit 4 of 4

    Visit 4, continued

    Treatment plan

    Treatment continued unchanged

    • Patient satisfied
    • Physician satisfied
    18
    OutcomesCase Nº 056

    Outcomes

    Scores over time

    EASI020Baseline: EASI 1212V1: EASI 1717V3: EASI 77BaselineV1V2V3V4BSA020Baseline: BSA 15%15%V3: BSA 6%6%BaselineV1V2V3V4IGA04Baseline: IGA 22V1: IGA 33BaselineV1V2V3V4

    V = follow-up visit. Each scale starts at zero.

    19

    A 19-year-old male with moderate atopic dermatitis.

    EC2Change Case File Nº 056

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