The Evolving Treatment Landscape of Atopic Dermatitis and Other Dermatological Conditions - Episode 4
Brian Keegan, MD, PhD, and Michael Cameron, MD, FAAD, describe treatment options for patients with atopic dermatitis.
Casey Butrus, PharmD: Dr Keegan, explain the treatment landscape for atopic dermatitis [AD] and the therapeutic categories and options we have available for our patients.
Brian Keegan, MD, PhD: When I think about it, there are 4 major treatments we can offer patients. Bucket No. 1 would be basic skin hygiene. That includes a variety of emollients, topical over-the-counter medications, are skin-barrier-type products, steering clear of things that may irritate their skin. Allergens, fragrances, and things like that may make things more challenging. Patients have a variety of experiences with that because they’re able to get a lot of those products on their own, through a variety of outlets.
The second bucket would be topical-type medicines. Those are things that come in creams, tubes, and jars. Topical steroids are the 1 we use most commonly, but there are also nonsteroid anti-inflammatories that fall into a couple of different groups of categories. There are also several prescription barrier creams available, and patients may need our assistance accessing those products.
The third bucket would be phototherapy. Light treatment can help calm the inflammation that’s going on the skin for patients. This is useful when we talk about larger body surface areas. There were some comments about the time-consuming nature of treating patients, whether they’re pediatric and need assistance from the parents or they’re adults and the monotony. Who wouldn’t want another 15, 20, 30 minutes in our day? If it takes that long to apply the medicines you have, that could be challenging. Phototherapy and its ability to treat larger body surface areas are very useful for some patients.
My fourth bucket would be systemic treatments. Years ago, when I started my practice, there was little or nothing to offer patients in terms of specific unlabeled treatments. Everything we used was borrowed from a variety of other specialty areas. In trying to use other medicines that calm the immune system, we’ve been fortunate that a number of new molecules have been identified as injectable and pill medicines. We can offer those to patients when we think they’d benefit from systemic treatment.
We can also offer a combination of these things. We can help someone choose the right type of skin hygiene products, but maybe they’d benefit from a topical, a phototherapy, or a topical medicine and a systemic treatment in combination, depending on what their challenging areas are. Fortunately, there are a lot of new, good options to discuss, but it can be quite challenging for patients, depending on their cost: what they need to do to buy this or that, what that costs any given day or week, what products I have to purchase, co-payments to come to the office, etc. I went through it quickly. Michael probably has some things he wants to add that I’ve glossed over, in terms of treatment approach for patients.
Michael Cameron, MD, FAAD: That was a great summary. It’s an exciting time to be treating AD. When I was in residency, our choices were phototherapy, methotrexate, and dupilumab, which has the brand name Dupixent. It was a generational therapy. The only generational therapies I’ve seen in dermatology were Accutane [isotretinoin], Humira [adalimumab], and Dupixent. By generational, I mean it changed the game completely. Since Dupixent came out, we’ve had new other biologics, like Adbry [tralokinumab], which was approved a year ago. We have lebrikizumab from Eli Lilly and Co coming soon. On the biologic space, it’s exciting.
In the oral small molecule space, we have JAK inhibitors. We have upadacitinib [Rinvoq] and abrocitinib [Cibinqo], which are great oral small molecules that are highly efficacious. We’ll jump into a discussion at some point on JAK safety, which I’m passionate about. But those are great systemic options.
In the topical space, historically we haven’t had great options. We had things like tacrolimus [Prograf], which was greasy and burns. It has a black-box warning. We can discuss the merits of that black-box warning and if it should even exist, but it does have it. Then we had Elidel, or pimecrolimus, which isn’t highly efficacious. We were limited from a nonsteroidal perspective a few years ago until Eucrisa, or crisaborole, got approved. More recently we have Opzelura approved, which is a topical ruxolitinib, so it’s a topical JAK inhibitor. We’ve had a real improvement in our nonsteroidal treatment of atopic dermatitis. One thing I’ve found—I’m curious what you have to say, Dr Keegan—is that patients with atopic dermatitis are much more reticent of using steroids than, for example, patients with psoriasis. Do you agree?
Brian Keegan, MD, PhD: I agree. Some of it may also be age dependent. A lot of parents are very reticent to use topical steroids on their kids.
Michael Cameron, MD, FAAD: Some of it is age, but even long-haul or adult patients are always worried about the rebound from steroids, steroid resistance, and thinning of the skin from steroids—much more than our patients with psoriasis. It’s exciting that we have even more nonsteroids coming to market, hopefully soon. We recently saw phase 3 data from Zoryve, topical roflumilast, which is approved for psoriasis but has good data in the eczema population, and some impressive data from tapinarof [Vtama], which is also approved for psoriasis. Hopefully we’ll have that in the eczema population soon. It’s an exciting time to focus on atopic dermatitis.
Casey Butrus, PharmD: That goes back to your point of the inflammatory nature of atopic dermatitis and plaque psoriasis, which are both chronic inflammatory diseases. It will be interesting to see the expanded indications coming soon for these treatments that may be only for plaque psoriasis right now.
Transcript edited for clarity.