Christopher Bunick, MD, PhD, Reviews Crucial Discussion of Biologics for AD and More

Dermatology Times’® Editorial Advisory Board member, Christopher Bunick, MD, PhD, recently presented at the 2023 Fall Clinical Dermatology Conference for PAs and NPs alongside Lauren Miller, PA-C, and Gil Yosipovitch, MD, to discuss how biologics and advanced systemic therapies are able to improve the lives of patients with atopic dermatitis (AD). Bunick, an associate professor of dermatology at the Yale School of Medicine and a physician-scientist, and his colleagues reviewed numerous topics during their panel discussion, including the mechanism of action of cytokines in AD, how all AD patients can’t be grouped into the same category, what to do when providers have a patient that is on a biologic or systemic therapy and they have an impetiginized AD flare, and more.

Bunick also stressed the importance of improving patient care by encouraging more collaboration between dermatologists, physician assistants, and nurse practitioners.

“It's been a real privilege to speak here at the Fall Clinical Dermatology Conference for PAs and NPs. As we move into the future, it's very obvious that there's more and more coordination between physicians, dermatologists, PAs, and NPs, and it's very important that we together learn how to communicate, work together, and have the same fundamental knowledge and skills to care for our patients,” concluded Bunick.

Bunick: I'm Christopher Bunick, associate professor of dermatology from Yale University and I'm here in Orlando at the Fall Clinical Dermatology Conference for PAs and NPs, and I just participated in a workshop session on atopic dermatitis biologics, and this was a very fun workshop. We covered a number of topics. First, we simply started with the mechanism of action of cytokines in atopic dermatitis. While there's a lot of emphasis on interleukin 4, interleukin 13, and interleukin 31, which are clearly very important and dominant cytokines, we touched on the fact that atopic dermatitis is a multi-cytokine disease, that there are a number of other cytokines that also play a role in skin inflammation and itch. That being said, we also talked about how all atopic dermatitis patients can't be lumped into the same basket. They're not all the same. And one of the scientific terms to describe the fact that there's different groups or populations in atopic dermatitis, it's called molecular endotypes, as we tried to connect the science, right to go from bench to bedside, what we're finding is different atopic dermatitis patients have different molecular endotypes. And what that means is, they may have different transcriptional or proteomic profiles in the skin that may drive the inflammation and itch that they're experiencing. And so we have to tailor those therapies to be able to account for these different endotypes. And that is one of the major reasons that we have to have and understand the multiple therapies for atopic dermatitis.

So in this workshop, we really focused on a few of the biologics in particular, the IL-4 and IL_13 targeting dupilumab, the IL-13 targeting tralokinumab, and the IL-13 targeting lebrikizumab. And what's really important to understand about each of these biologics is that they target different molecular entities. So, dupilumab is targeting the interleukin 4 receptor, whereas the IL-13 biologics are targeting the cytokine, but tralokinumab and lebrikizumab actually bind different faces of the IL-13 cytokine. Almost 180 degrees opposite each other. And there are consequences of how this binding then effects cycling of IL-13 through the IL-13 receptor alpha 2. So we touched on some of that biology and we emphasize that the biologics in atopic dermatitis are working outside the cell in terms of their targeting, whereas the new JAK inhibitors in dermatology are targeting the signaling machinery inside the cell. So it's an important dichotomy: outside the cell and inside the cell, ultimately all trying to target the ultimate gene transcription of the programs that leads to the inflammation and itching our patients. And this is very important information to know for just the everyday clinical practice of taking care of atopic dermatitis patients.

What we wanted to emphasize in the second half of this workshop was how to implement and when to implement biologics and advanced systemic therapies in atopic dermatitis. A lot of times, a provider may want to wait until the skin is really bad covering 90% or 100% of the body with inflammation and scale, fissuring, or you may want to wait till a patient is so itchy, they're not sleeping, but what we talked about is really how to define moderate to severe atopic dermatitis that sometimes patients that have maybe 10% or even 15% body surface area, but depending on where that body surface area activity is, like the locations the hands, the feet the genitals, the scalp, or how severe that itch might be, that these are all appropriate situations to use biologic therapies or advanced systemic therapies like JAK inhibitors. I think it's very important as we move into the future, to actually realize that atopic dermatitis patients suffer a lot and you can't always get a full picture of how much they're suffering just by an EASI score or an itch score, but the whole combination looking at that EASI score, that itch score, the quality of life and just the overall experience of the patient, what they've tried, what they failed. All of that plays a role in how you choose and I think me personally, I like in my patients, I've found that going to the advanced biologics and systemic therapies are in fact giving better control of the disease, control the itch, and restoring confidence and functionality to patients’ lives and so that's why I really enjoy learning and talking about these types of therapies because they are changing the lives of atopic dermatitis patients day in and day out.

One of the other aspects of biologic therapy and atopic dermatitis that we talked about is what do you do when you have a patient that is on a biologic or systemic therapy and they have impetiginized atopic dermatitis flare because we know that atopic dermatitis patients are more prone to Staphylococcus aureus infections. And I presented a couple of cases of patients of mine that had impetiginized flares of their atopic dermatitis while on a biologic. And how did I manage that? Well, I found that using the narrow spectrum antibiotics sarecycline combined with bleach baths is a wonderful way to treat this and not expose the patient to long-term broad-spectrum antibiotics unnecessarily, but to pick something that's very safe, has less side effect on the gut microbiome, and also protects the patient from antibiotic resistance. I think that this narrow-spectrum antibiotic has very good anti-staphylococcal properties that a lot of dermatologists don't know about. And so I think that this set of cases that I've presented highlights how we can incorporate narrow-spectrum antibiotics and antibiotic stewardship and other diseases besides acne, in this case, atopic dermatitis.

It's been a real privilege to speak here at the Fall Clinical Dermatology Conference for PAs and NPs. As we move into the future, it's very obvious that there's more and more coordination between physicians, dermatologists, PAs, and NPs, and it's very important that we together learn how to communicate, work together and have the same fundamental knowledge and skills to care for our patients. And I think that being here and interacting with the PAs and NPs has been a wonderful experience, and I really look forward to how we as the specialty of dermatology can grow not just as physicians but as care providers and work together as a team to really bring good care to our patients because in the end, it's always about the patient. And the patient wants us in the health care profession to work as a team and I think that learning and working as a team here at Fall Clinical has been a very good experience.

[Transcript edited for clarity]