Matthew Zirwas, MD: Cutting-Edge Advances in Atopic Dermatitis and Itch Management

Matthew Zirwas, MD, covered topics and pearls related to dermatitis in a series of presentations at the Society of Dermatology Physician Associates (SDPA) 22nd Annual Fall Dermatology Conference in Las Vegas, Nevada. His sessions, titled, “Managing Atopic Dermatitis: Innovations, Challenges, and Care Strategies” and “Practical & Effective Approaches for the Itchy Patient,” outlined the latest advancements in the treatment of atopic dermatitis and other itch-related conditions.

TRANSCRIPT:

Zirwas: I'm Dr Matthew Zirwas. I'm a board-certified dermatologist in Columbus, Ohio. I'm part of DOCS dermatology group. I did my residency at the University of Pittsburgh, and I've been specializing in eczema and associated disorders for the last 20 years.

Dermatology Times: What topics did you cover during your session on atopic dermatitis at SDPA Fall 2024?

Zirwas: So, I am so excited to be giving this SDPA atopic dermatitis talk. It blows people's minds. If I could put it in one word, everything you've learned about atopic dermatitis is wrong. I love having the chance to really reeducate people on what we now think about atopic dermatitis and how to take the best care of your patients. So, for example, did you know that in adults, the vast majority don't have any flexural involvement? It's much more common to be on your extremities or your trunk. Did you know that in adults, the majority of them have zero atopic comorbidities? So not just that they don't have terrible atopic comorbidities; the majority of them don't have any. And these things are not my opinion. This is what the data shows. And those two things should immediately really change for you, how you think about diagnosing atopic dermatitis. But then the next thing is, after you diagnose it, what do you do? So the first thing is, patients want to know, "Why did I get this?" Because, again, we know that in kids, it's a genetic disease. In adults, it's not a genetic disease, purely an acquired disease, and a disease that we know diet plays a huge role in. Again, this is the data, not my opinion, right? An acquired disease. So, we now know how to explain to them why they got it. We know how to explain to them what to do about their diet. We know what natural supplements have randomized, double-blind, placebo-controlled trials showing that they work. And just to give you the thumbnail answers, it's air pollution, soap, and hard water - and not just soap that you bathe in, the laundry detergent in your clothing. In diet, it's not a food allergy. It's an abnormal intestinal microbiome. And the natural supplements that we use, we use an oral ceramide, we use fish oil, and we use a specific probiotic. All three of those have randomized, double-blind, placebo-controlled trials. Now that's not even getting into the great stuff about the drugs that we have now. And I'm just going to put it simply; all of the drugs that we have are amazing. They just work so well for these patients and are so safe. From a really high 10,000-foot perspective, here's what we now know. JAK inhibitors; not only do they not increase the risk of cardiovascular disease and venous thromboembolism, but they are also strongly protective. They prevent cardiovascular events and Veno thromboembolic events. That's what the data shows us. Number two, Dupixent, what we know about that now. The earlier you start in childhood, the better a job it does of preventing the atopic march. Lebrikizumab, the new guy on the block. This is a drug that is amazing because whenever you space it out to once every 4 weeks, it actually works better than it does if you continue it every 2 weeks.So, you start them every 2 weeks, then you break them down to every 4 weeks. And then the newest, newest kid on the block that will hopefully be approved really soon is Nemluvio, which is our first IL-31 inhibitor. This drug, what makes it amazing is completely painless injections, or at least as close as you could possibly get to completely painless, is once a month from day 1, and it literally has no meaningful side effects. No conjunctivitis, no arthralgias, no nausea, no acne, no nothing. So, it's one of the easiest drugs to use that we've got in all of dermatology. And then finally, our new topicals. It remains the case that topical ruxolitinib (Opzelura) is the most effective and fastest topical. Nothing is changing that. New kid on the block that won't be here till March now is Vtama. That should be getting approved down to age 2 in atopic dermatitis. Really a very, very effective drug - much more effective than I expected. Its special points; naturally derived and incredibly low systemic absorption. And then finally, the other guy that got approved this year is our good old Zoryve cream. Great drug because it is a PDE-4 inhibitor. So we're very comfortable with how good the safety profile is. But unlike the old PDE-4 inhibitor that we have, no burning or stinging. So, a really great, safe option that we're very comfortable with the mechanism of action.

Dermatology Times: What upcoming advancements in atopic dermatitis are you looking forward to?

Zirwas: What I am excited about for the upcoming year in the world of atopic dermatitis is just what is coming next. I have learned to not even make predictions. Because if you had told me 2 years ago that I would be saying the main driving factor for atopic dermatitis is air pollution, I would have literally laughed at you and thought you were out of your mind. But the research came through. Now we know that is the big driving factor for why atopic dermatitis got so much more common since the 1970s. Air pollution, car exhaust - that's the reason for the urban, rural gradient, right? What we've learned about atopic dermatitis has been really amazing. I'm really excited about getting to really get into using EBGlyss and Nemluvio and really see how good they are in our patients. And I'm also really excited to see what happens with the OX40 drugs. So, we've got 2 OX40 pathway inhibitors in the pipeline that are doing their phase 3 studies. I think these are going to be really interesting drugs that might give us the chance to be able to treat our patients for a defined period of time, then stop treatment and have it be months or years before their disease comes back. It remains to see if that really does turn out to be what happens, but that's what I'm excited to see, is if we have really, what we will call a long-term disease-modifying pathway now in the world of atopic dermatitis. I'm also excited that we're hopefully going to get our first drugs that are specifically approved for hand eczema. Hand eczema is really tough because it's essentially always an overlap between irritant contact dermatitis and atopic dermatitis, with maybe some allergic contact dermatitis thrown in. So, it's a really tough overlap diagnosis, and we're hopefully going to get our first FDA-approved therapies specifically for hand eczema. Very excited about that as well.

Dermatology Times: What key points did you share during “Practical and Effective Approaches for the Itchy Patient?”

Zirwas: So, itch is getting to be such a fun topic. So we got to think about itch in a couple of ways. So first, how do we think about itch now? Like, how do we think about it differently? Here's the key thing, number one, and I'm going to lump in both itch in general and prurigo nodularis because I really think of them both in a very similar way. So itch without much rash, immediately you should go to neuropathic itch. As a resident, I was always trying to work these people up. They can have this, they can have that, they can have all kinds of things. The likelihood that you're going to find an underlying cause that the itch was the presenting symptom of is close to 0. Now, they might have a long history of diabetes or liver impairment or renal impairment that might be driving their itch, but that's going to be medical history, not something that you find. What about cancer? The only cancers that are statistically over-represented are bile duct malignancies. That one's going to be easy to diagnose because they only get itchy after they're yellow. And then second, hematologic malignancies, you're going to pick that up with your lymph node exam and in your CBC, right? So don't get stuck in working these people up and looking for a cause. Just go to treating them. So treating these people, number one, if they've got widespread or they've got localized that is recalcitrant. First, do not prescribe hydroxyzine or doxepin. In my opinion, it is malpractice to prescribe either of those drugs. They have so many side effects, especially anticholinergic, and I've seen so many patients who have fallen or had significant cognitive impairment from them. The two drugs that really work. Number one, the best drug for itching is mirtazapine. It used to be called Remeron, but mirtazapine is the generic name, 15 milligrams qHS. It's an old antidepressant. 10% of people will get an increased appetite from it, but otherwise incredibly well tolerated, and really helps people with sleeping. If that guy doesn't work, my second-line agent is gabapentin. Harder to use because of the dosing. Unlike the mirtazapine that's just 1 pill, qHS, the gabapentin is at least twice a day, probably best 3 times a day. The problem is it makes people feel like a zombie. Most patients can't stand taking it. Those are my two big systemic agents. Topical by far, the best thing out there is Dermeleve. So Dermeleve is a strontium-based topical. This is a great drug for things like notalgia paresthetica and brachioradial pruritus. And they've got a serum for scalp that is the best thing I've ever seen for scalp itching. That's my go-to for localized and if that doesn't work, then I'm likely to go to the systemics pretty easily. Prurigo nodularis, again, I want to go back to, don't get stuck in the workup. In the vast majority of these people, you're not going to find anything, and even if you do find something, treating the underlying comorbidity doesn't help with the itch. Fortunately, we've got two phenomenal drugs at this point. So, we've got Dupixent. Dupixent works a little faster for the nodules, but slower for the itch. Nemluvio, which I just talked about for atopic dermatitis, works much faster for the itching than Dupixent. A little bit slower for getting the nodules to go away, but now we've got these 2 great options.

[Transcript has been edited for clarity.]