At the 2024 Fall Clinical Dermatology Conference for Physician Assistants (PAs) and Nurse Practitioners (NPs), Dr. James Song, Director of Clinical Research at Frontier Dermatology Partners in Seattle, Washington, delivered a comprehensive session on navigating therapy options for atopic dermatitis (AD). In an interview with Dermatology Times, Dr. Song shared insights into the treatment landscape, focusing on recent advancements and practical considerations for clinicians.
The Significance of Effective AD Management
Dr. Song underscored the severe consequences of ineffective atopic dermatitis treatment. Referencing a 2023 study, he emphasized that inadequate AD treatment can result in increased use of psychostimulants and nootropics, with a noticeable decline in their usage following the initiation of dupilumab treatment. This highlights the necessity for timely and efficient intervention.
Determining Systemic Therapy Usage
According to Dr. Song, systemic therapy should be contemplated for patients with moderate to severe AD, particularly when the disease significantly impacts their quality of life, affects special sites (such as the hands, face, scalp, and genitalia), and when intensive topical therapies fail, particularly due to the overuse of ultrapotent topical corticosteroids (TCS) resulting in therapeutic failures.
First-Line Systemic Therapy: Dupilumab
Dupilumab remains the preferred first-line systemic therapy for AD. As per the latest guidelines from the American Academy of Dermatology, all working group members favored it due to its efficacy in skin clearance and itch reduction. Dr. Song highlighted its effectiveness over time, offering remarkable durability and safety without necessitating laboratory monitoring or concerns over boxed warnings.
Comparison of Biologics: Dupilumab, Tralokinumab, and Lebrikizumab
Dr. Song compared the three main biologics targeting IL-13:
- Dupilumab: Noted for its fast-acting nature and significant efficacy, approved for patients aged 6 months and older, and effective for other type 2 comorbidities.
- Tralokinumab: Exhibits similar efficacy to dupilumab, approved for patients aged 12 and older, with a numerically lower incidence of conjunctivitis but requiring more injections.
- Lebrikizumab: Although not yet FDA-approved, it 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 demonstrated that patients who failed dupilumab achieved meaningful improvement when transitioned to other treatments such as abrocitinib or upadacitinib.
JAK Inhibitors: An Alternative Approach
JAK inhibitors like upadacitinib and abrocitinib offer faster and deeper levels of itch and skin response compared to biologics. They are particularly effective for patients with challenging-to-treat areas, high itch scores, or specific AD phenotypes such as nummular eczema or AD-psoriasis overlap. However, clinicians must be cautious of the boxed warnings and the necessity for laboratory monitoring associated with JAK inhibitors.
Practical Considerations for Clinicians
Dr. 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 the desired outcome with their current treatment. Initiating 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.
In conclusion, Dr. Song stated, “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.”
