Reviewing Unmet Need, Clinical Priorities for Patients With Atopic Dermatitis

Shawn Kwatra, MD, FAAD, director, Johns Hopkins Itch Center, identifies unmet need for patients with atopic dermatitis and shares what factors clinicians and patients prioritize when deciding on a treatment option.

Read the full transcript:

I'm Shawn Kwatra. I'm the director of the Johns Hopkins Itch Center in Baltimore, Maryland, also an associate professor of dermatology.

How do atopic dermatitis symptoms affect patients’ quality of life?

The hallmark of atopic dermatitis is intense itch, and this can lead to significant disruptions in sleep, quality of life, and social relationships. The appearance of lesions in atopic dermatitis can make folks feel self-conscious. I have many teenagers and young adults that feel very self-conscious about the appearance of their eczema. But overall, itch is a mediator of many of the comorbidities of atopic dermatitis.

If you're not sleeping well, you're more likely to have mental health conditions like anxiety, depression, even things like ADHD in children. That's also a mediator of inflammation—if you're not sleeping well, you're more likely to have increased systemic inflammation. That's why you see all sorts of comorbidities, even cardiometabolic comorbidities in patients with severe atopic dermatitis.

What unmet need still exists for patients with atopic dermatitis?

Before 2017, when dupilumab was approved, the treatment of atopic dermatitis was unbelievably difficult. We had to rely on very nonspecific immunosuppressants that were not targeted at all, had many side effects, and also needed very frequent lab monitoring. Treating a patient with eczema was incredibly complex.

But in recent years, wow, we've had such a flurry of new options. It's truly the best time in history to have eczema. What we're finding is there are so many new treatment options that can be tailored to patients’ specific disease.

Dupilumab was approved. It's every two weeks. Also, we know tralokinumab’s another biologic targeting IL-13 administered every two weeks, but can also go down to every four weeks if patients have controlled disease. Those are excellent options.

We also have very rapidly effective options, small molecule inhibitors, the JAK inhibitors. We have excellent drugs like abrocitinib and upadacitinib. We also have the topical JAK inhibitor ruxolitinib. These options have enabled us to go farther and farther away from non-specific agents. Prednisone, intramuscular Kenalog, and steroids are becoming less and less common, as these drugs are very unsafe for our patients.

With greater implementation of these new agents, patients are getting rapidly acting agents that can control their disease very quickly. They're able to stay away from both systemic steroids and topical steroids, which can cause hypopigmentation, atrophy, and telangiectasias. That's why there's been a big need for topical agents, short-acting oral agents, and long-acting agents. Now, we have quite a variety of options for our patients.

What factors do clinicians prioritize when considering a treatment option?

Patient preference is important. Whenever I'm explaining all of the different options to patients, we don't have a ton of time, but we have to cover a ton of ground.

I basically say, we're very lucky that in the last few years, we have now had many approvals of drugs for atopic dermatitis. There are different categories of agents. There are injectable agents that are very targeted, monoclonal antibodies. And we go through what those options look like—that they would involve an actual injection—to make sure folks are okay with that. Some folks are totally okay with that.

Other people are looking for a pill they could take. In that case, an oral JAK inhibitor may be more appropriate for those patients. We also go through other diseases that they have. Do folks have any history of certain illnesses, blood clots, anything like that?

Those are all things that factor into the decision making. Do they have other atopic comorbidities like asthma, or do they have conjunctivitis? We can tailor the side effect profile of each drug toward the risk profile for each patient. Luckily, by and large, atopic dermatitis patients are a very, very healthy population.

Looking through all of the different phase 3 studies, with the monoclonal antibodies and also small molecule JAK inhibitors, it’s very rare that any serious adverse events happen. Especially for oral JAK inhibitors, treatment in patients with atopic dermatitis appears to be much different than previous reports in patients with rheumatoid arthritis who have a significant comorbidity burden. My colleagues and I can proceed with a great deal of confidence that the therapies that we give will be well tolerated and also rapidly effective.

Those are all considerations that factor in for patients. I think that allowing patients these options and the choice has meant a lot. I've been surprised by some of the different preferences patients have, but I think they truly appreciate being able to decide what type of drug would fit in best with their life and the lifestyle they'd like to have.

This transcript has been edited for clarity.