In the second round of breakout sessions at the Horizons in Advanced Practice meeting in Las Vegas, Nevada, Omar Noor, MD, FAAD; Douglas DiRuggiero, DMSc, MHS, PA-C; and Lakshi Aldredge, MSN, ANP-BC, DCNP, FAANP, focused on common challenges and innovations in treating plaque psoriasis and atopic dermatitis (AD). To foster collaboration and discussion around the cases, the meeting attendees were divided into 3 groups, with each Horizons chair moderating a session. DiRuggiero presented the first case of a woman aged 27 years who had eczematous lesions covering more than 20% of her body surface area. Noor presented the second case of a woman aged 25 years who presented with erythematous and scaly patches on her face, neck, and upper trunk.
Pediatrics and Topicals
Aldredge led the third breakout group, which tackled issues in AD in pediatrics and topical treatment options. She shared the case of a female patient aged 12 years with moderate AD that had been worsening over the past several months. The patient presented with 8% BSA; areas impacted included the hands, arms, and trunk. The patient reported persistent itching, redness, and discomfort, particularly on her hands. Like the previous patients, she reported sleeping difficulties stemming from the itch.
The history revealed the patient had onset of symptoms when she was 10, Aldredge reported. There is a familial history of asthma (her father) as well as a history of hay fever (her mother). Past treatments included a short history of oral antihistamines during severe itching episodes. She also received crisaborole 2%.
The patient is using daily emollient and moisturizer as well as a topical corticosteroid (mometasone 0.1%). The patient’s parents report they have been reluctant to try topical therapies on the hands. Moreover, they are concerned about the long-term use of corticosteroids, especially the thinning of skin. Both the patient and the parents are looking for fast-acting, effective treatment, Aldredge told attendees.
Guidelines and New Research
Aldredge reviewed the treatment landscape of topical therapies for AD, including prescription moisturizers, topical corticosteroids, topical calcineurin inhibitors, topical PDE4 inhibitors, topical JAK inhibitors, and topical antimicrobials. In doing so, she noted the GRADE (Grading of Recommendations Assessment, Development and Evaluation), strength of recommendation, and the severity level for which the agents might be appropriate as put forth by the 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations.1
In taking a closer look at the options, Aldredge shared research from the phase 3 TRuE AD1 (NCT03745638) and TRuE AD2 (NCT03745651) trials that indicatedruxolitinib (Opzelura; Incyte) may be a rapidly effective option. “When switched from vehicle to ruxolitinib, the proportion of patients with IGA 0/1 [Investigator’s Global Assessment score of 0 or 1] increased rapidly, and mean BSA decreased rapidly after 4 weeks,” she told attendees.2
In addition, she noted the overall bioavailability of ruxolitinib cream is low (a fraction of that of the oral formulation), and the average steady-state trough plasma concentrations at the highest strength (1.5% twice daily) were less than 20% of ruxolitinib half-maximal inhibitory concentration for JAK2 inhibition in human whole blood assays. The data also found no correlations between concentrations at steady state and any hematological changes, except for a transient increase in platelets at week 2.3
These highlights bring up important issues that need to be considered in real-world patients, Aldredge noted. She led a thoughtful discussion of these issues with her breakout group.
Aldredge reviewed the long-term safety data for ruxolitinib reported in the TRuE AD1 and TRuE AD2 studies, which looked at 0.75% and 1.5% ruxolitinib cream compared with vehicle. Researchers found low ruxolitinib plasma concentrations, she said. There were minimal application site reactions, and most reported AEs were considered unrelated to treatment. The most common AEs were upper respiratory tract infection and nasopharyngitis; there were minimal reports of notable serious infections, malignancies, MACE, and thrombotic events.2,3
Case Questions
- How does the involvement of sensitive areas like the hands, which are frequently used and exposed, influence the treatment choice?
- How does long-term efficacy influence the decision to initiate ruxolitinib in young patients? How does ruxolitinib compare with other systemic JAK inhibitors used in treating AD?
- How does the potential for sustained relief compare with concerns about corticosteroid use over time?
- How does a quick response affect the management of moderate AD in pediatric patients?
- What issues arise in pediatric patients using the cream over a relatively large BSA?
- Under what circumstances would combining topical ruxolitinib with other treatments be warranted, and what precautions should be taken?
The patient and her parents considered the options presented and decided to initiate topical ruxolitinib 1.5%. The cream was applied twice daily to the affected areas. The patient was advised to continue with daily emollients and an oral antihistamine for breakthrough itching. After 8 weeks of treatment, there was a 50% reduction in EASI scores, indicative of significant improvement in eczema severity, Aldredge said. Similarly, the patient reported a marked reduction in pruritus as well as improved sleep. She had no applicationsite reactions and reported no AEs. Moreover, the parents reported treatment satisfaction as well as reduced anxiety concerning topical treatments.2,3
Aldredge’s group acknowledged the importance of addressing parents’ concerns when considering certain treatment options. Ultimately, leveraging research and data can help clinicians devise a thoughtful treatment plan to meet the patient’s needs and address parents’ concerns.
Concluding Thoughts
Research continues to shed light on AD pathophysiology, and these new insights allow for increased treatment options for patients, according to the Horizons Chairs. The conversations within the breakout sessions pointed to an exciting time for research and new solutions. Based on the conversations, there is an increased dedication to finding the most appropriate, safe, and rapidly effective treatment for each patient by leveraging special issues like comorbidities, response, severity, and age.
References
- AAAAI/ACAAI JTF Atopic Dermatitis Guideline Panel; Chu DK, Schneider L, Asiniwasis RN, et al. Atopic dermatitis (eczema) guidelines: 2023 American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology Joint Task Force on Practice Parameters GRADE- and Institute of Medicine-based recommendations. Ann Allergy Asthma Immunol. 2024;132(3):274-312. doi:10.1016/j.anai.2023.11.009
- Papp K, Szepietowski JC, Kircik L, et al. Long-term safety and disease control with ruxolitinib cream in atopic dermatitis: results from two phase 3 studies. J Am Acad Dermatol. 2023;88(5):1008-1016. doi:10.1016/j.jaad.2022.09.060
- Gong X, Chen X, Kuligowski ME, et al. Pharmacokinetics of ruxolitinib in patients with atopic dermatitis treated with ruxolitinib cream: data from phase II and III studies. Am J Clin Dermatol. 2021;22(4):555-566. doi:10.1007/s40257-021-00610-x
