Acne & Rosacea, Drug Actions, and Atopic Dermatitis Updates With James Del Rosso, DO

James Del Rosso, DO, a practicing dermatologist and research director at JDR Dermatology Research in Las Vegas, Nevada, senior vice president of clinical research & strategic development at Advanced Dermatology & Cosmetic Surgery in Maitland, Florida, and an upcoming presenter at Music City SCALE 2023, spoke with Dermatology Times® to preview his sessions on acne and rosacea management, drug actions, current treatment options for atopic dermatitis, and JAK inhibitors vs monoclonal antibodies.

“Hopefully you'll be [at SCALE] or get a chance to see the presentations. My goal is that you get something out of it that you can use in your practice,” said Del Rosso.

To access the full SCALE 2023 agenda, click here. Additionally, Del Rosso’s sessions include:

1. Drug Actions, Reactions, and Interactions: Focus on Newer Systemic Therapies – May 18th, 2023, 8:10am CT
2. Atopic Dermatitis: Where Are We Now? - May 18th, 2023, 3:30pm CT
3. The Ongoing Debate: JAK Inhibitors vs Monoclonal Antibodies – May 18th, 2023, 4:10pm CT
4. Cases About Faces – Acne, Rosacea, and Beyond – May 18, 2023, 5:00pm CT

Transcript

Del Rosso: Hi, I’m Dr. Jim Del Rosso, a dermatologist practicing in Las Vegas, Nevada for 26 of my 36 years in dermatology. I direct a research center here; I’m affiliated with Thomas Dermatology called JDR Dermatology Research. And I'm also the senior vice president of clinical research and strategic development for Advanced Dermatology and Cosmetic Surgery, assisting them with research projects and analysis of data. So, I’m pretty busy and involved in a lot of educational initiatives and programs, etc.

But we're here to talk about the SCALE meeting, which is a meeting that goes on every year in Nashville, and this year, it runs from May 17th to May 21st. And I'm very thankful to Dr. Gold and Dr. Biesman for inviting me over the past few years because I always enjoy going to Nashville and I enjoy the music. I always get a couple of pairs of really nice cowboy boots when I'm there. There's a place I go to, I love it. But we get very involved in dermatology. So, I'm actually talking about a few areas. One of them is Cases About Faces. And here I actually focus mostly on rosacea, because I think there's been some new information and new therapies with rosacea. First of all, to distinguish the clinical features that the patient has. Identify those and then to correlate those with the actual therapies, medical therapies that will address papulopustular lesions and the erythema around them. Topical alpha agonists that can address the vascular proliferation that leads to persistent facial erythema, devices that can also address that, and treat the telangiectasiaswhichdon't respond to any type of medical therapy. But for the papulopustular lesions, we have a variety of different therapies, including some of the newer ones like there's an encapsulated benzoyl peroxide, which is extremely effective and very well tolerated because of the encapsulation for papulopustular rosacea that I think some people are having little difficulty with the idea of benzoyl peroxide, but the data on the efficacy and tolerability and safety is very, very good.

I also go over the other agents like sub antibiotic dose doxycycline and the agents that we typically had like metronidazole, azelaic acid, and ivermectin, a topical minocycline foam. So, I talk about how to correlate these and then the entity of if patients have been applying topical steroids repeatedly to their face. In this case, the case of the patient that had rosacea and how to manage that because that's a different entity. And it requires, along with rosacea, anytime a patient has it. In this case, even more, very gentle skincare in combination. I'll show a case with sub antibiotic dose doxycycline that did very good. So that's the Cases About Faces.

I also do Drug Actions, Reactions, and Interactions, where I talk about 3 different mechanisms phosphodiesterase-4 inhibition topically, with a newer agent topical roflumilast, which really stands out in terms of efficacy and tolerability for plaque psoriasis, but also under development for atopic dermatitis, and seborrheic dermatitis with very good results, and excellent tolerability. We'll talk about that mechanism and the features of that agent. Also, topical tapinarof which is the first agent that's available as an aryl hydrocarbon receptor agonist, which is an important intracellular mechanism approved for the topical treatment of plaque psoriasis, but also under evaluation for atopic dermatitis, also shown to be very effective, and well tolerated. Both roflumilast and tapinarof are essentially free of precautions and warnings and no systemic safety signals. So that's good news.

Then we get into 2 discussions about atopic dermatitis. I talk about where we are now and I go back and look at some of the conventional topical and systemic agents we've had, what they may still bring to the table, but some of their drawbacks. And then I look at not only the topical newer agents that we have, like topical ruxolitinib, which is a Janus kinase inhibitor that's approved and very effective and when used properly, is very, very safe for atopic dermatitis in appropriate patients like adolescents and adults. And then the systemic drug where we have monoclonal antibodies like dupilumab approved down to the age of 6 months for moderate to severe atopic dermatitis in patients that are amenable or who need systemic therapy. Topical alone has not been adequate. We'll go through that. [Dupilumab is] highly effective and really does not need any baseline laboratory monitoring and has been shown to offer many advantages.And then also, tralokinumab, which is selective against IL-13, where dupilumab targets IL-4 and IL-13.

IL-13 inhibitors like tralokinumab are very effective in this data with approval in adults in really the same type of patients that dupilumab was treated for in its trials with very effective results and not needing any baseline laboratory monitoring. Because the studies with these drugs did not show anything that showed up that you needed to monitor at baseline. Obviously with individual patients, you may decide to do what you feel is appropriate, but at least according to the label.

Then lebrikizumab is likely going to be here later this year and also inhibits IL-13. It's different in some ways than tralokinumab, but the efficacy and safety data so far is very promising. Then we'll get into that discussion of Janus kinase inhibitors, and we have 2 oral Janus kinase inhibitors, abrocitinib and upadacitinib that are approved for also moderate to severe atopic dermatitis in patients that have not adequately responded or could not adequately be controlled on prior systemic therapies, including biologics, and we'll talk about those 2 agents. Now those 2 agents do have some baseline monitoring recommendations and follow up recommendations due to potential side effects, some of which are highlighted in the box warnings. But when you look at the data on both of those agents, and they're collecting more and more data over time, when you look at just those box warnings of major cardiovascular events, serious infections, malignancy, thromboembolism, changes in blood counts, etc. You can see that in the population of patients that don't have the high levels and the high amounts of comorbidity of the patients treated with other Janus kinase inhibitors, and even some that are being looked at or used in dermatology, upadacitinib is used beyond dermatology as an oral agent, but was different populations, older patients. The data in the monograph on the box warnings is specifically calling out patients that are over 50, typically, at least 60 years of age. So, someone in my category that had rheumatoid arthritis and other comorbidities, where the risks of those adverse events are significantly higher based on looking at the populations.

In the atopic dermatitis populations which are younger, they can carry some comorbidities and some issues like cigarette smoking, utilizing oral contraceptives, maybe being hypertensive, but the rates of those reactions are significantly lower, based on collecting data in that populations of patients and looking at the numbers, and I will go over that, too. I don't want to make it sound like there's no concern for how to monitor patients, but the risks are substantially lower. So, you really need to get to know the patient, know what the risk is. And for those patients that need the next level because they're miserable and they're not responding to the other therapies, these drugs have been shown to offer additional benefits. And we'll talk about some of that, and also patients that maybe had issues or couldn't take dupilumab, utilizing tralokinumab. There's a little data going back and forth on that and maybe going the other way. So, we talk about a lot of things in a short period of time. I've gone a little long here, but I did have a lot to discuss at the meeting. So hopefully you'll be there or get a chance to see the presentations. My goal is that you get something out of it that you can use in your practice. Thank you. Hope to see you in Nashville.

[Transcript is edited for clarity and space]