Available Therapeutics and Upcoming Advancements in Atopic Dermatitis and Prurigo Nodularis

“One of the main themes of our session was every dermatologist, every physician, every provider who takes care of dermatology patients should be asking their patients about itch,” said Shawn Kwatra, MD, in an interview with Dermatology Times at Fall Clinical 2024.

Kwatra, professor and chair of dermatology at the University of Maryland School of Medicine, recently presented sessions on “Highlights from Making the Connection Between Prurigo Nodularis, Atopic Dermatitis, and Itch” and “Gamechangers in Nonsteroidal Topical Management of Atopic Dermatitis: The Next Generation.”

During his sessions, Kwatra discussed the shared pathophysiology between different itch conditions; the importance of asking patients about their itch severity at every appointment; FDA approvals of dupilumab, tralokinumab, lebrikizumab and more for atopic dermatitis; FDA approvals of dupilumab and nemolizumab for prurigo nodularis; upcoming abrocitinib and povorcitinib for prurigo nodularis; and overuse of steroids in the management of atopic dermatitis.

Kwatra’s Key Highlights

1. Pathophysiology and Shared Mechanisms of Itch

Kwatra discussed the role of shared inflammatory pathways in conditions such as atopic dermatitis (AD) and prurigo nodularis (PN). Type 2 inflammation, particularly involving cytokines IL-4, IL-13, and IL-31, is increasingly recognized as a key contributor across various itch subtypes. Understanding these mechanisms emphasizes the rationale behind targeting these pathways to reduce inflammation and itch severity in both AD and PN.

2. Emerging and Recent FDA Approvals for Itch Conditions

The discussion highlighted the evolving landscape of biologics and targeted therapies. Dupilumab, first approved in 2017, remains a mainstay for managing AD and is also approved for PN. New agents, including lebrikizumab (IL-13 inhibitor) and nemolizumab (IL-31 receptor inhibitor), are providing expanded options for AD and PN treatment. Additionally, JAK inhibitors such as abrocitinib and upadacitinib were noted for their efficacy in oral administration, while topical ruxolitinib offers targeted relief for PN with a favorable safety profile. Kwatra’s team has been instrumental in trials for promising therapies such as povorcitinib, another JAK1 inhibitor for PN.

3. Standardized Itch Assessment for Clinical Practice

Kwatra emphasized the importance of integrating itch severity assessments into routine dermatology care. He suggested using a standardized scale (0 to 10) to gauge itch intensity, which has been shown to directly correlate with quality-of-life improvements when scores are reduced. This practice can particularly benefit patients with skin of color, where itch severity may go underreported, thus contributing to better health equity in dermatology.

4. Non-Steroidal Topicals as Game-Changers

Kwatra advocated for the increased use of non-steroidal topicals to avoid long-term adverse effects of corticosteroids, such as hypopigmentation and skin atrophy. The session discussed the advantages of agents like topical ruxolitinib, crisaborole, and roflumilast. Emerging treatments such as tapinarof, an aryl hydrocarbon receptor modulator, represent an important advancement, particularly for steroid-sparing regimens in chronic itch management.

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