<p>Shared decision making is an essential component of atopic dermatitis (AD) care. Patients and families must fully understand the treatment options, and, when choosing a treatment, a useful framework is to consider its efficacy, accessibility, safety, and tolerability (EAST). In addition, incorporating patient preferences, addressing treatment hesitancy, and navigating family dynamics can help improve outcomes.</p>

Shared decision making in AD is an important concept. Organizations such as the National Eczema Association have been advocating this for a very long time, holding workshops on how to engage in shared decision making. For chronic conditions such as AD, patients and their families (in the case of a pediatric patient) have to be all in. Saying, “Do this and call me next month,” is not going to work if they are not actually going to follow through.

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There is a lot of treatment hesitancy among individuals with AD; for example, many patients have corticophobia. There are also concerns about immunosuppressants in general and about US Food and Drug Administration (FDA) boxed warnings for several of the medications that we use for AD. Back in 2006, boxed warnings were added for both topical tacrolimus and pimecrolimus, and families were concerned because it read as follows: “This may be associated with cancer.” Can you imagine giving something like that to your child or using it yourself?

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Treating children is also complicated because you really have 2 focuses. First, you have to get the patient involved in the discussion if they are old enough, and that could be someone as young as 3 years. If you are talking about injections, a 3-year-old patient will have strong opinions. And then parents may not agree about treatment, perhaps more so if they are divorced or separated. One parent may be physically present during the appointment while the other may be on the phone, and they may often be arguing, which makes things more difficult.

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Shared decision making means sitting with patients and their families to make sure that they understand the treatment options, the risks and benefits of each treatment, and what to expect from treatment. However, sometimes patients become frustrated because they feel that they have not been given a chance to talk or voice their concerns. Once they are fully on board, then we go forward from there.

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In 2020, I was coauthor on an article that described 4 characteristics to consider when comparing different AD medications to help foster the shared decision-making process, and we called it EAST. E is for efficacy. How effective is the drug? This can encompass a lot of aspects, such as how fast it works, how deep and reliable the effect is, and how many and what types of patients may respond to it. Giving patients some guidance about anticipated efficacy is important. This type of understanding comes from both published data and experience. A is for accessibility, including costs, which can be a complex situation, depending on insurance and patient circumstances. S is for safety and all the situations we have to consider with each medication. T is for tolerability, which can be a really important component for patients, especially because some of these agents are going on the skin. We have to go through the characteristics described in EAST for each drug, and you can imagine that this takes time, energy, and knowledge to do it right.