In their session, “Atopic Dermatitis: Inspecting the Evidence & Learning From Expert Experience,” presented at the 2022 Fall Clinical Dermatology Conference, Emma Guttman, MD, MPH, and Alexandra K Golant, MD, shared insights into atopic dermatitis (AD). They were joined by a patient speaker who shared his experience with the treatment of AD.

They kicked off the session by describing how biologics target the disease pathway for AD. “IL-13 is now considered to be the major cytokine of the TH2 pathway, but it’s also considered the central cytokine for AD. IL-13 increases in skin of patients with AD and its expression correlates with disease severity and chronicity,” said Dr Guttman. Type 2 cytokines IL-4/13 affect the skin but also affect other organs beyond the skin, including causing food allergy, eosinophilic esophagitis, allergic rhinitis, and asthma. 

Next, they reviewed the clinical trial data for new and emerging agents to treat moderate to severe AD:

• Dupilumab blocks the IL-4Ra subunit, interfering with IL-4 and IL-13 signaling, with long-term safety for up to 172 weeks in adults
• Lebrikizumab targets IL-13 and prevents the formation of IL-12Ra1/IL-4Ra without interfering with IL-13Ra2, demonstrating 53-week efficacy and safety with lebrikizumab monotherapy among patients with moderate to severe AD (ADvocate 1 and 2, responder analysis only)
• Tralokinumab targets IL-13 and prevents binding to both IL-13Ra1 and Ra2 decoy receptor, with long-term efficacy through 56 weeks (interim analysis of ECZTEND OLE) and long-tern safety through 56 weeks (interim safety analysis of ECZTEND)

Drs Guttman and Golant moved further to illustrate individualized treatment plans based on patients and disease-related considerations. Dr Golant suggested primary management considerations, such as:

• Redefining disease severity classification
• Knowing when to initiate systematic therapeutics
• Personalizing treatment plans based on patient/parent/family needs and preferences

Lastly, Dr Golant discussed strategies to involve patients and their families in the shared decision-making process. Some of the cornerstones of shared decision-making in AD are:

• Know where your patient is at in their process
• Know what your patient has tried (in detail)
• Understand your patient’s treatment goals…and share your own
• Be aware of other important motivating factors

She also touched upon some of the common misconceptions, including:

• AD is a “skin only” disease
• AD is a childhood-only disease
• AD is the patient’s (or parent’s) fault or the result of something they are doing…or not doing
• AD can resolve by simply eliminating allergens or irritants
• There is no risk to undertreat AD

In conclusion, some of the things to consider as a dermatologist treating AD are:

• Patient priorities: timeline
• Patient profile: history and comorbidities
• Preferred route of delivery (oral vs injections)
• Barriers to adherence: frequent travel, changing schedules, etc.

Reference
Guttman E, Golant AK, Hershey S. Atopic dermatitis: inspecting the evidence & learning from expert experience. Presented at: Fall Clinical Dermatology Conference 2022; October 20–23, 2022; Las Vegas, NV.