Question

Jacie steps up her TCS and uses wet wrap therapy to help address her itchy flare. Her skin is not responding, and she says that she has not been able to tolerate the TCNIs in the past. Her SCORAD index is 53. What is the BEST next step?

A) Call the dermatologist and suggest she change Jacie's medication to methotrexate weekly for at least 8 weeks to ensure any response will be fast and enduring
B) Suggest that Jacie add crisaborole lotion as a moisturizer, applying it as needed and under wet wraps to increase skin hydration
C) Explain that with a SCORAD index of 53, she now has severe AD and will need to consider systemic therapy
D) Use motivational interviewing to ensure that Jacie is completely adherent, and ask her to come back in a week

Answer 1

Jacie's eczema is not responding to wet wrap therapy and she cannot tolerate TCNIs; thus, it is best to reassess treatment options and consult a dermatologist if needed. Using motivational interviewing could help ensure Jacie's adherence to her treatment plan. A follow-up visit in a week is advisable for further assessment.

Step-by-step explanation:

The question concerns the optimal management of eczema not responding to typical treatments like wet wrap therapy and intolerance to topical calcineurin inhibitors (TCNIs). Given that persistent itching and a high SCORAD index of 53 indicate significant disease activity, Jacie's treatment plan requires reassessment. The best next step would be discussing other therapeutic options such as systemic agents (for instance, oral corticosteroids, immunosuppressants or biologic drugs) or phototherapy. Consulting a dermatologist might become necessary for Jacie, considering the severity of her symptoms.

Furthermore, using motivational interviewing to ensure Jacie's complete adherence to her treatment regimen is crucial. Non-adherence can often contribute to the apparent non-response to therapy. This technique involves engaging with the patient in a collaborative conversation, working through any ambivalence towards treatment, and supporting her autonomy in decision-making to foster better adherence. Finally, having Jacie return in a week for follow-up will allow for monitoring of symptom progression and adjustment of treatment as necessary.