Deciphering Atopic Dermatitis Therapy Options

At the 2024 Fall Clinical Dermatology Conference for PAs and NPs, James Song, MD, director of clinical research at Frontier Dermatology Partners in Seattle, Washington presented a comprehensive session on deciphering therapy options for atopic dermatitis (AD). Song shared valuable insights into the treatment landscape, focusing on the latest advancements and practical considerations for clinicians in an interview with Dermatology Times.¹

The Importance of Effective AD Management

Song emphasized the severe consequences of not treating atopic dermatitis effectively. Citing research from 2023, he highlighted that inadequate treatment of AD can lead to increased use of psychostimulants and nootropics, with a notable decrease in their use following the initiation of dupilumab treatment. This underscores the need for timely and effective intervention.²

When to Consider Systemic Therapy

Song explained that systemic therapy should be considered in patients with moderate to severe AD, especially when the disease impacts quality of life significantly, when special sites (such as the hands, face, scalp, and genitalia) are affected, and when intensive topical therapies fail, particularly with the overuse of ultrapotent topical corticosteroids (TCS) leading to therapeutic failures.³

First-Line Systemic Therapy: Dupilumab

Dupilumab remains the preferred first-line systemic therapy for AD, as all working group members publishing the latest guidelines from the American Academy of Dermatology favored it due to its efficacy in skin clearance and itch reduction. The therapy is particularly effective over time, offering excellent durability and safety without the need for laboratory monitoring or concerns over boxed warnings.⁴

Comparing Biologics: Dupilumab, Tralokinumab, and Lebrikizumab

Song compared the 3 main biologics targeting IL-13:

• Dupilumab: Fast-acting with significant efficacy, approved for patients aged 6 months and older, also effective for other type 2 comorbidities
• Tralokinumab: Similar efficacy to dupilumab, approved for patients aged 12 and older, with a numerically lower incidence of conjunctivitis but requiring more injections
• Lebrikizumab: Not yet FDA-approved but shows promise in clinical trials

Addressing Dupilumab Non-Responders

For patients who do not respond adequately to dupilumab, switching to other biologics or JAK inhibitors can be effective. Studies have shown that patients who failed dupilumab achieved meaningful improvement when switched to other treatments such as abrocitinib or upadacitinib.⁵

JAK Inhibitors: A Viable Alternative

JAK inhibitors like upadacitinib and abrocitinib offer faster and deeper levels of itch and skin response compared to biologics. These are particularly effective for patients with difficult-to-treat areas, high itch scores, or specific AD phenotypes such as nummular eczema or AD-psoriasis overlap. However, clinicians must be mindful of the boxed warnings and the need for laboratory monitoring associated with JAK inhibitors.⁶

Practical Considerations for Clinicians

Song advised that biologics are generally easier to initiate, especially in high-risk patients due to the absence of boxed warnings and the lack of required laboratory monitoring. However, he encouraged clinicians not to hesitate to switch to JAK inhibitors or other biologics if patients are not achieving an ideal state with their current treatment. Starting with a JAK inhibitor can be considered if a patient has failed previous systemic therapies, presents a JAK-responsive clinical phenotype, or has comorbid conditions treatable with JAK inhibition.⁷

Song concluded, “One of the primary challenges in treating AD is that we actually have a lot of good options. It's just getting patients on those medications. Some of that could be access in that patients don't have insurance that pay for some of these medications. But it's also getting them comfortable graduating from a topical therapy to a systemic therapy. Sometimes that can be a pretty big jump for some people, and just like we see with many other diseases, oftentimes, prescribers are waiting too long before they have the conversation about starting a systemic therapy.I'm convinced that if we could get patients on some sort of systemic therapy, the vast majority of them are going to have some type of meaningful improvement.”

References

1. Song J. Deciphering atopic dermatitis therapy options. Presented at: 2024 Fall Clinical Dermatology Conference for PAs and NPs; May 31-June 2, 2024; Scottsdale, AZ.
2. Yildirim AM, Pradhan T, Zinn ZA. Dupilumab treatment for atopic dermatitis is associated with decreased utilization of psychostimulants for attention deficit hyperactivity disorder: A retrospective cohort study. J Am Acad Dermatol. 2023;88(4):956-958. doi:10.1016/j.jaad.2023.01.025
3. Simpson EL, Bruin-Weller M, Flohr C, et al. When does atopic dermatitis warrant systemic therapy? Recommendations from an expert panel of the International Eczema Council. J Am Acad Dermatol. 2017;77(4):623-633. doi:10.1016/j.jaad.2017.06.042
4. Davis DMR, Drucker AM, Alikhan A, et al. Guidelines of care for the management of atopic dermatitis in adults with phototherapy and systemic therapies. J Am Acad Dermatol. 2024;90(2):e43-e56. doi:10.1016/j.jaad.2023.08.102
5. Bai H, Murase EM, Ashbaugh AG, Botto NB, Murase JE. Diagnostic testing of eczematous dermatitis with incomplete response to dupilumab. J Am Acad Dermatol. 2022;87(3):692-695. doi:10.1016/j.jaad.2022.03.047
6. Gao Q, Zhao Y, Zhang J. Efficacy and safety of abrocitinib and upadacitinib versus dupilumab in adults with moderate-to-severe atopic dermatitis: A systematic review and meta-analysis. Heliyon. 2023;9(6):e16704. Published 2023 Jun 2. doi:10.1016/j.heliyon.2023.e16704
7. Gargiulo L, Ibba L, Malagoli P, et al. Management of Patients Affected by Moderate-to-Severe Atopic Dermatitis with JAK Inhibitors in Real-World Clinical Practice: An Italian Delphi Consensus. Dermatol Ther (Heidelb). 2024;14(4):919-932. doi:10.1007/s13555-024-01135-x