Management of Atopic Dermatitis in Pediatric and Adult Patients - Episode 1
Dr Vivian Shi provides an overview of treatment options for atopic dermatitis patients in different age groups.
Raj Chovatiya, MD, PhD: Hello, and thank you for joining us for this HCPLive® MEDcast series titled, “Management of Atopic Dermatitis in Pediatric and Adult Patients.” I’m Dr Raj Chovatiya, an assistant professor of dermatology at the Northwestern University Feinberg School of Medicine in Chicago, Illinois. I’m also the director of the Center for Eczema and Itch and the medical director of the clinical trials unit.
George Han, MD, PhD: I’m Dr George Han, an associate professor in the department of dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York, where I direct clinical trials in teledermatology.
Raj Chovatiya, MD, PhD: We’re going to have a fascinating discussion about the management of atopic dermatitis [AD] in different age groups and with other patient factors, and we want to think about how to select the right treatment for the right patient. To discuss more of this, we’re joined by the renowned Dr Vivian Shi, an associate professor in the department of dermatology at the University of Arkansas for Medical Sciences in Little Rock, Arkansas. Thank you for joining us. Let’s get started.
Right off the bat, I’m throwing this your way, Vivian, because I don’t often get to have you in this circumstance. George and I were chatting a bit and the treatment landscape for AD is crazy. There’s a treatment here and a treatment there. You blink and there’s an oral, an injectable, a topical. It’s hard to keep track; 2022 was insane. That’s part of the reason we’re all a little confused. If you blinked, many things came out. Walk us through some of the new stuff that we have available at our disposal, Vivian.
Vivian Shi, MD, FAAD: You’re absolutely right. It’s been super exciting. I blinked several times, and boom—there’s that much more in the toolbox. That’s exactly how I feel. We can start with topicals and systemics. How does it sound to break them up that way?
Raj Chovatiya, MD, PhD: Go for it.
Vivian Shi, MD, FAAD: We have our topical ruxolitinib cream that’s approved for eczema for age 12 and older, so for teenagers and adults. This is an exciting breakthrough in topical treatment, for not just atopic dermatitis but also inflammatory conditions across the board. We’ve had topical corticosteroid since the beginning of time. We had calcineurin inhibitors, PDE4 inhibitors, and JAK inhibitors, which I find exciting as a small molecule inhibitor. The beauty is that because it’s a small size in molecular weight, it’s able to penetrate through the skin barrier a lot better for these inflammatory conditions. It’s very efficacious, but we lack head-to-head trial data for ruxolitinib cream and some existing topicals. Cost is another issue, and there’s a limit on the 20% BSA [body surface area] application. In practice, it’s trial and error to see what they can afford and find the best anatomical location to apply it. That’s the approved topical treatment.
We have 2 exciting ones approved for psoriasis: tapinarof cream, which is the aryl hydrocarbon receptor agonist, and roflumilast cream, which is a PDE4 cream for psoriasis in children 6 years and up. They’re not approved for atopic dermatitis, but they hold a lot of potential for eczematous conditions. We’re using those in some of our patients when we can, pun intended, get our hands on them.
Raj Chovatiya, MD, PhD: Vivian, I want to see if you and George differ in your thoughts. George, how is topical ruxolitinib cream fitting in to your practice?
George Han, MD, PhD: For so long, we’ve gotten used to significant sacrifices and trade-offs when it comes to topicals. You’ve got the topical steroids, and we’ve all seen those patients come in their 30s and 40s after using decades of topical steroids. Their skin is in terrible shape from the steroid-induced atrophy and those adverse effects. It’s great that we now have good tools to combat that. We sacrifice some efficacy and tolerability because of the stinging and burning that individuals get from some other options, but topical ruxolitinib doesn’t have those problems.
When you look at the phase 2 data—they were smart to include a separate triamcinolone group—they were interesting to see. Even though it wasn’t a direct comparison, you got to see the bar graphs on a similar scale. You saw that this works as good or a little better than triamcinolone 0.1%, which every dermatologist is familiar with. That has helped us contextualize where to put this. In the beginning, the hard part was wrapping our heads around where we put this in terms of JAK inhibitors and absorption. How much gets in the bloodstream? It’s not a negligible amount at higher body surface areas. I tell my patients that they will read scary things associated with systemic JAKs, but that 20% BSA is there to protect you and me because under that area, we don’t have to worry about systemic effects.
This works as a good topical that has little trade-off. Otherwise, you can put it anywhere you want on your body surface area. You’re not going to get terrible stinging and burning. In some postmarketing studies of tacrolimus, up to 50% of patients got that. We see that a lot. Topical phosphodiesterase inhibitors in the past have been challenging in that sense too. We finally have something effective and safe when used appropriately.
Raj Chovatiya, MD, PhD: You raise an interesting point about this lack of desire for head-to-head data. That’s something that we’re all a bit confused about in dermatology: trying to figure out the right therapy for the right circumstance. I love the way you brought up some of the phase 2 data that patients may not know about for topical ruxolitinib. For newer oral therapies, the 2 JAK inhibitors, abrocitinib and upadacitinib, those trial programs are interesting because they had direct comparison built into the phase 3 programs. We got an idea: to look at the previously approved therapy dupilumab and how it’s stacked up with our oral JAK inhibitors. To me, the 2 oral JAKs are exciting because we have multiple dosing options for patients and the ability to rapidly improve both signs and symptoms. We have some of the deeper responses in itch than we’ve seen in some time, but also responses that last for a long time.
That box warning is the thing we end up spending so much time thinking about. From all the data that seem to be emerging, our long-term data look quite promising and will offer another nice option alongside biologic therapies. In the case of oral JAK inhibitors, as far as the label goes, good candidates are patients who have experienced some systemic therapy previously. Vivian, there have been updates in biologic therapy as well, in terms of newer age groups included in existing therapies and even another therapy in the case of tralokinumab. What’s your take on that?
Vivian Shi, MD, FAAD: It’s very exciting. For the first time, we have a biologic for babies. When I was in training, I wouldn’t have even dreamed about it. I was writing prescriptions for immunosuppressants like methotrexate for patients who were still wrapped in blankets. That was profound.
Raj Chovatiya, MD, PhD: I don’t miss that.
Vivian Shi, MD, FAAD: I don’t miss that at all. Dupilumab is approved down to age 6 months, so even very young patients are eligible for this. I call it the designer drug. It’s safe, easily dosed, and well tolerated. It’s unlike anything we’ve had in this group. Patients can enjoy the relief in itch and in their lesions just as older kids and adults have been experiencing the past few years. It’s super exciting that we now have dupilumab; it’s a household name. We’ve used it for a long time in different age groups.
Raj Chovatiya, MD, PhD: Five years—I couldn’t imagine.
Vivian Shi, MD, FAAD: That’s a long time in the world of atopic dermatitis.
George Han, MD, PhD: I use those 6-month data to shame some of the older patients into doing it. I’m saying, “If 6-month-old babies get this injection, what are you waiting for? What are you scared of?”
Raj Chovatiya, MD, PhD: That’s funny. Vivian, you were going to give us your quick preview on trial tralokinumab. I’d love to get your thoughts.
Vivian Shi, MD, FAAD: It’s always nice to have more options. We’re still not where we want to be in terms of available biologic options, like we have in psoriasis, but having more than 1 option is a landmark in our world. Tralokinumab is approved only for adults with atopic dermatitis. Hopefully we’ll have it approved for the teenagers soon. It works similarly to dupilumab, but it’s a little different. Instead of targeting IL-4 and IL-13 and signaling like dupilumab, tralokinumab targets IL-13 pathway only. We still see the improvement in atopic dermatitis over time, and it’s sustained. There’s itch and sleep improvement along with other secondary end points.
Transcript Edited for Clarity