Unlocking Optimal AD Treatment: From Triggers to JAK Inhibitors

In the recent Dermatology Times Expert Perspectives video series, “Exploring the Multifaceted Landscape of Atopic Dermatitis Care at the 2024 AAD Meeting,” 4 leading dermatologists explored key benchmarks, emerging trends, personalized medicine approaches, long-term safety considerations, and the integration of novel therapies in the management of atopic dermatitis (AD).

Triggers and Comorbidities

Mark Lebwohl, MD, dean for clinical therapeutics at the Icahn School of Medicine at Mount Sinai in New York, New York, shared insights into the multifaceted approach to treating AD. He emphasized the significance of identifying and addressing specific triggers for AD in patients, as these can directly impact treatment outcomes. Lebwohl underscored the importance of recognizing triggers such as excessive bathing, environmental factors like cold dry air or sweat, and comorbidities such as asthma. He emphasized tailoring treatments to each patient’s unique circumstances and said, “Identifying the factors that trigger AD in particular patients should have a direct effect on the treatments that you suggest.

Moreover, Lebwohl highlighted the correlation between comorbidities and treatment selection. For instance, patients with asthma and AD can benefit from treatments like dupilumab that address both conditions simultaneously. He warned against the use of systemic steroids in patients with comorbidities like osteoporosis, advocating for safer alternatives. Discussing the evolving landscape of AD treatments, Lebwohl pointed out the array of new and diverse therapies available. From nonsteroidal topical treatments like ruxolitinib to systemic therapies such as janus kinase (JAK) inhibitors like upadacitinib, the options are expanding rapidly.

Lebwohl expressed optimism about the future of AD treatment. He explained: “Our therapeutic armamentarium for the disease has grown very quickly and looks like it will continue to grow. There are a number of additional anti IL-13 drugs on the horizon—also, drugs that target OX40 antibodies, which appear to be promising for AD. So, I think we’re going to experience in AD what we have experienced in the [past] decade for psoriasis where we have an explosion of new, better, safer treatments that help our patients live better lives.”

Benchmarks for Optimal Outcomes

Christopher Bunick, MD, PhD, clinical associate professor at Yale School of Medicine in New Haven, Connecticut, shed light on the potential of JAK inhibitors in treating AD, emphasizing their role in achieving significant milestones, such as EASI 90 (Eczema Area and Severity Index) and itch reduction. According to Bunick, there exists a notable disparity between the effectiveness of biologics and JAK inhibitors in reaching the EASI 90 threshold, prompting the need for therapies to prioritize these end points to optimize patient outcomes comprehensively.

He said, “It is going to be really important with the development of therapies and the use of therapies like JAK inhibitors to really pay attention to the achievement of EASI 90 and itch 0 or 1 to optimize our patient outcomes.” While acknowledging the progress made, Bunick stressed the necessity of aiming higher, stating, “We want 90%, 100% of our patients achieving EASI 90, EASI 100. So, there is room for innovation.”

Bunick highlighted the promising safety profile of JAK inhibitors, suggesting they could potentially become first-line therapies for AD. He remarked, “As we learn more about the long-term safety of the JAK inhibitors, I think that what we’re going to find...the safety data only gets more reassuring.” Bunick emphasized the importance of reaching new efficacy thresholds with JAK inhibitors, asserting that these milestones are crucial for unlocking their full potential in dermatology. “These benchmarks and these achieving new thresholds of EASI 90 and itch reduction are helping us really unlock the potential of JAK inhibitors, not just in AD, but in all of dermatology,” he said.

JAK Inhibitor Long-Term Management

Ruth Ann Vleugels, MD, MPH, MBA, dermatologist at Brigham and Women’s Hospital and Boston Children’s Hospital in Massachusetts, highlighted the crucial aspect of patient selection when considering JAK inhibitors for treating AD. In her insights, she emphasized that while JAK inhibitors offer rapid relief and high efficacy, identifying the right candidates is paramount for long-term success.

Patient selection involves thorough assessments, including inquiries about cancer history, clotting issues, tobacco usage, and cardiac risk factors. Addressing and modifying these factors are essential for ensuring the safety and efficacy of JAK inhibitor therapy. “Our job is going to be to modify those risk factors, just like we would with any other our other patients on systemic therapies,” she said. Vleugels stressed that appropriate patient selection instills confidence in administering long-term treatment with JAK inhibitors.

Moreover, she shed light on the extensive experience with JAK inhibitors predating their approval for AD. This underscores the familiarity and efficacy of these medications across various inflammatory and autoimmune conditions. She expressed the importance of regular monitoring during extended JAK inhibitor therapy. Quarterly laboratory checks for blood counts, liver function, kidney health, and lipid levels are standard practice to ensure patient safety and optimal treatment outcomes.

Interpreting AAD Guidelines

The American Academy of Dermatology’s AD guidelines serve as a comprehensive overview of available treatments and their evidence levels. Michael Cameron, MD, dermatologist at Cameron Dermatology PLLC and Mount Sinai in New York, New York, believes they lack detailed guidance on the best treatment options for patients. He said, “The guidelines are really just a compendium of available options....I find also there’s no nuance between therapies as everything is recommended. And everything has high level of evidence. “

Cameron acknowledged the guidelines’ value in addressing skin hygiene practices, finding the commentary helpful in navigating conflicting advice on bathing frequency and product usage. He emphasized the importance of updated recommendations that advocate for topical and oral JAK inhibitors. He said, “I think the biggest thing from my perspective is that the guidelines are updated to strongly recommend both topical ruxolitinib as well as the oral JAK inhibitors, which is great news for patients. It’s another thing to cement their really important role in the [treatment] of AD patients.