At his session, “New Developments in Atopic Dermatitis,” presented at the 2022 AAD annual meeting, Eric Lawrence Simpson, MD, FAAD, introduced personalized approaches to atopic dermatitis (AD) therapies, and the new topical therapies that are on the horizon.

He opened by addressing risk alleles associated with AD as a genetic disease both in the skin barrier and in the immune system. Next, he added that this is also an environmental issue that influenced the manifestation of the disease referencing a few of the studies he was a part of.

“There are some other studies outside of our group that found that having a cat was not good for prevalence of AD, that having a dog may not be protective,” Dr Simpson stated. “But always take these FD association studies with a grain of salt or wait until there’s some RCT data before you start saying ‘ok, I’m going to have my patient kill their cat…’” he jokingly continued.

He emphasized that physicians should not act on their patient care via the FD studies.

After discussing his insights on the prevention of AD (you can read in detail here), Dr Simpson discussed immune activation in AD patients emphasizing that targeting type-2 was important despite heterogenous presentation. He stressed that what they’re trying to do is figure out what are the phenotypes or the endotypes? Should dermatologists be phenotyping or endotyping patients in order to personalize their therapeutic treatments? He stated there are already studies looking into these but that they haven’t been conclusive as of yet.

Next, he presented the chronic eczematous eruption of elderly and addressed the spectrum which included:

• prurigo nodularis;
• erythroderma; and
• hand eczema.

He showcased the heterogenous disease course from infants to elderly which displayed the severity entering very early onset with remission in children as young as 2 years old. This could deviate into very early onset without remission or become the “silent disease” which doesn’t present itself until either childhood, teenager, adult, or even elderly in which it’s considered very late onset. This would also determine the burden of disease from children to elderly.

Some of these burdens are lesser-known Dr Simpson shared. These include dyspigmentation, hand and facial dermatitis—both which add additional burden. Another list of burdens include:

• skin infections;
• guilt from scratching;
• burden and stress on family;
• attempting to chase the allergen or cause;
• complicated topical regimens;
• physician disagreement;
• embarrassment;
• stigma;
• false positive lgE testing;
• internet misinformation; and
• altering activities via lifestyle alongside work and school difficulties.

Continuing on, Dr Simpson gave an overview for topical therapy noting that they induce clearance usually via TCS, have flexible maintenance due to many options including reactive, proactive, TCS, or non-steroidals, and they have a brief clearance protocol for flares.

One of the topical therapies he discussed was ruxolitinib cream which is a new therapy which fills the gap for potent nonsteroids via cream base, can be compared to a medium potency of topical steroid, and has a likelihood of direct/indirect on itch neurons through rapid action. He added it has minimal burning, which was a benefit over tacromilus and crisaborole, and that its overall safety looked great during short-term and onto 52 weeks.

Dr Simpson then discussed when to use systemic therapy if aggressive topical therapy is not achieving adequate control of the disease. He emphasized that, first, adequate education must be delivered, infection should be addressed, there should be a large impact on quality of life, and exhaust reconsidered diagnosis such as CTCL, allergic contact dermatitis, etc. He added that considering phototherapy was also important

He then noted the 4 factors to consider when choosing a systemic such as:

• comorbidities;
• severity;
• previous therapy; and
• risk aversion.

With that, he introduced tralokinumab, an anti-IL-13 that serves as an IL-13 cytokine blocking agent. It likely has a more modest efficacy than dupilumab and is slower onset but long lasting.

He also introduced methotrexate, an immunosuppressant, and noted the factors in which physicians should utilize it such as if there’s a moderate patient, a patient transitioning from cyclosporine, dupilumab isn’t cover or if the patient is with Medicare. Physicians can also use it as an add-on to dupilumab, or if they’re uncertain of the diagnosis. Dr Simpson stated that methotrexate should NEVER be used when liver comorbidities are present, with women who are of child-bearing potential without contraception, or if there’s chronic and frequent alcohol use.

Finally, Dr Simpson presented his practical considerations that noted that patients should review medication guides, and physicians should consider any history that includes clotting risks, cancer, serious infection, or cardiovascular. He concluded that medications, such as Abro CYP2C19, CYP2C, and CYP3A4, should be reviewed, vaccinations must be up to date, and to stop use when patients are pregnant or lactating.

Reference
Simpson E. New developments in atopic dermatitis. Presented at: AAD Annual Meeting; March 25-28, 2022; Boston, MA.