Advanced therapeutics for severe atopic dermatitis

While topical therapies are often sufficient for mild or moderate eczema, adding systemic agents to the treatment regimen may become necessary for more severe disease, according to Peter Lio, M.D., Northwestern University Feinberg School of Medicine and Medical Dermatology Associates of Chicago.

“There are few systemic agents FDA-approved for children in general, let alone for atopic dermatitis. However, these agents may be used safely and efficaciously in children and have been for quite some time,” he told colleagues Friday at the Society for Pediatric Dermatology Annual Meeting in Austin, Texas.

“There is trepidation about using systemics in children in general,” he says, and this is unsurprising as few such agents have been adequately studied in this group, let alone approved by the U.S. Food and Drug Administration (FDA), so most need to be used off-label.

As a result, he says, “Many clinicians are not comfortable with them, so it falls upon pediatric dermatologists disproportionately.”

Key agents include dupilumab (Dupixent, Sanofi), which is FDA-approved for adolescents, and cyclosporine, which he favors. However, he cautions that it must be used with care because it is associated with real risks, including hypertension, kidney damage, hypertrichosis and cancer/infection risk.

After topical care has been maximised, cyclosporine can offer rapid and sustained relief for many patients, he explains.

“When used carefully and for a relatively short period of time (several months), it can be both safe and effective to get things under better control. In certain cases, this may not be possible or suitable, so dupilumab can be used in patients 12 and up, but also has been used in younger patients off-label,” he says.

Atopic dermatitis is a complex, multi-faceted disease, he emphasizes. It’s really not one disease at all, but a collection of similar conditions.

“It often takes several modalities to get durable improvement and break the vicious cycle of atopic dermatitis,” he explains. “For many patients, just having them use triamcinolone when needed is simply not enough, so a more comprehensive plan that addresses skin barrier, bacterial imbalance, and behavioral components may be necessary to obtaining clear skin.”

There has not been much in terms of treatment development for severe atopic dermatitis over the last few decades but currently there are several potential products in the pipeline.

The JAK inhibitors, both topical and oral, seem extremely effective, although there are some important potential associated side effects to consider, he says.

“Topical tapinarof has great promise as a new non-steroidal agent, but we need to better understand its risks and benefits with larger studies,” he adds.