Case-Based Insights on Ruxolitinib vs Corticosteroids for Atopic Dermatitis

At a recent Dermatology Times Case-Based Roundtable custom event, “Balancing Efficacy and Comfort: Strategies for Effective Use of Non-Steroidal Topicals in Atopic Dermatitis,” James Q. Del Rosso, DO, shared perspectives on topical therapies for atopic dermatitis (AD). Del Rosso, a board-certified dermatologist and research director at JDR Dermatology Research in Las Vegas, Nevada, discussed the challenges associated with AD management, the limitations of topical corticosteroids, and the benefits of newer nonsteroidal treatments.

Case 1: A 15-Year-Old Adolescent With Severe Hand and Foot Eczema

Del Rosso presented the case of a 15-year-old high school student with significant eczematous dermatitis primarily affecting his hands and feet. His condition was characterized by intense pruritus, fissuring, and painful splits in the skin. The involvement of his hands was particularly distressing due to social concerns and affected self-esteem. Sleep disturbances due to intense itching further compounded his concerns.

The patient had a longstanding history of AD, with a family history of allergic rhinitis and other atopic conditions. He and his family were hesitant about prolonged corticosteroid use due to concerns about skin thinning and other potential adverse effects.

Ruxolitinib 1.5% cream (Opzelura; Incyte), a topical JAK inhibitor, was initiated twice daily, leading to a rapid reduction in itching and noticeable improvement in the skin’s appearance within days. By the 2-week follow-up, the patient reported significantly better sleep and a marked decrease in lesions. The regimen was maintained as needed: Treatment resumed when symptoms flared but was discontinued during remission. According to Del Rosso, the ability to cycle treatment effectively without prolonged exposure to corticosteroids was a key benefit in this case.

“When the disease comes back, he goes back to the therapy, but when the disease is gone, he can stop the therapy but certainly continue moisturization. He was extremely happy about it, and that is a pretty consistent response that we see,” Del Rosso said.

Case 2: A 23-Year-Old Radiology Technician With Chronic Hand Dermatitis

The second case involved a 23-year-old woman working as a radiology technician. Her AD was primarily localized to her hands, exacerbated by frequent handwashing and glove use. She had tried various topical corticosteroids, including triamcinolone and clobetasol. Although clobetasol provided rapid relief, concerns about long-term use led her to seek alternatives. Triamcinolone was less effective and took longer to alleviate her symptoms.

Her condition was characterized by lichenification and asteatotic-type AD rather than intense erythema. She also experienced severe pruritus, which disrupted her sleep. Given her reluctance to continue high-potency corticosteroids, topical ruxolitinib was introduced twice daily.

Within days, she reported significant relief from itching and better sleep quality. By the 2-week follow-up, her lesions had improved considerably and she expressed satisfaction with the treatment. Unlike with corticosteroids, she did not need to monitor how frequently she could safely use the medication, as ruxolitinib provided sustained benefits without the concerns associated with long-term steroid exposure.

“She had a lot of difficulty sleeping at night, such as falling asleep and staying asleep. That responded within days, and by the time she came back 2 weeks later, she was extremely happy with the results from the topical ruxolitinib,” Del Rosso said.

Comparing Ruxolitinib With Corticosteroids

Del Rosso reviewed a pivotal phase 2 clinical trial (NCT03011892) that compared topical ruxolitinib 1.5% twice daily with triamcinolone 0.1% cream twice daily over 4 weeks. The results demonstrated that ruxolitinib performed as well as, if not better than, the midpotency corticosteroid. Notably, even once-daily ruxolitinib application showed similar efficacy to triamcinolone used twice daily, though the recommended usage remains twice daily for optimal results.

Unlike corticosteroids, ruxolitinib is approved for application on sensitive areas such as the face, eyelids, and genital region without the risk of atrophy or telangiectasia. According to Del Rosso, this makes it a particularly attractive option for patients who require treatment in these areas.

Safety Considerations

One concern surrounding ruxolitinib is its inclusion of a boxed warning, inherited from systemic JAK inhibitors. However, clinical and real-world data indicate that systemic absorption remains minimal when used on up to 20% of body surface area as recommended. Thus, the risk of systemic adverse effects is negligible when the medication is applied appropriately.

Patient education plays a crucial role in ensuring optimal treatment outcomes. Del Rosso emphasized the importance of the following:

• Adherence to twice-daily application
• Recognizing and avoiding individual triggers
• Using gentle cleansers and moisturizers to maintain skin barrier function
• Understanding that ruxolitinib is a safe and effective nonsteroidal option that can be discontinued and restarted as needed

Broader Implications

For patients with moderate AD affecting 10% to 20% of body surface area, systemic therapy is often considered. However, findings from clinical trials demonstrated that ruxolitinib’s pharmacokinetic profile remains favorable even when used on the higher end of the approved body surface area range. This suggests that many patients with moderate AD can effectively manage their disease with topical ruxolitinib before resorting to systemic treatments.

Overall, Del Rosso’s roundtable discussion highlighted the evolving landscape of AD management. Topical ruxolitinib offers an effective alternative to corticosteroids, with rapid onset of action, a favorable safety profile, and the ability to treat sensitive areas without the concerns associated with steroid use.