Picking the Perfect Atopic Dermatitis Therapy with Matthew Zirwas, MD

Matthew Zirwas, MD, a board-certified dermatologist based at DOCS Dermatology in Columbus, Ohio, presented on contact dermatitis, atopic dermatitis, and recent literature at the Maui Derm NP+PA Fall meeting in Nashville.

Zirwas spoke with Dermatology Times about new and upcoming therapies including JAK inhibitors, the newly FDA approved lebrikizumab, and OX40s.

Dupilumab and Its Impact on CTCL

To start the discussion, Zirwas talked about the misconception that dupilumab increases the risk of cutaneous T-cell lymphoma (CTCL). He stated that the risk is very low, with 1 in 600 patients diagnosed with moderate to severe atopic dermatitis having CTCL. “I'm 100% comfortable saying the dupilumab does not cause CTCL,” he said. Dupilumab can clear reactive dermatitis, making CTCL diagnosable, but Zirwas underlined that there is no evidence linking dupilumab to CTCL.

Zirwas mentioned that about one in 250 patients on dupilumab experience life-affecting arthralgias. He advises stopping dupilumab if a patient develops arthralgias, as it will improve once the drug is discontinued.

JAK Inhibitors

“We now have 30,000 years of patient exposure in clinical trials closely monitored on JAK inhibitors that have shown zero increased risk of MACE, cancer or death,” Zirwas said. Despite the FDA's box warnings, he explains that there is no evidence of increased risk and reassures patients about the safety of JAK inhibitors.

Lebrikizumab and Its Benefits

Zirwas spoke about lebrikizumab (Ebglyss; Lilly), a recently FDA approved drug which has similar speed and efficacy to dupilumab. Lebrikizumab allows patients to switch from biweekly injections to monthly injections after 16 weeks, improving patient compliance. Notably, he stated that lebrikizumab does not help with asthma or allergies, making dupilumab a better option for patients with these conditions.

Nemolizumab and Its Unique Features

Next, Zirwas discusses nemolizumab (Nemluvio; Galderma Laboratories), an IL-31 inhibitor approved for psoriasis, which he says will soon be available for atopic dermatitis. Nemolizumab works faster for itch relief and has the fewest injections of any biologic for atopic dermatitis.“Probably the biggest benefit it will have in atopic dermatitis, the injections are once a month from day 1,” Zirwas said. He noted it has a novel delivery system with no preservatives, making it the least painful injection with the lowest rate of injection site reactions. The drug's unique delivery system and low systemic absorption make it a promising option for needle-phobic patients.

Topical Ruxolitinib and Its Fast-Acting Properties

Getting into topical therapies, Zirwas highlighted the fast-acting properties of topical ruxolitinib (Opzelura; Incyte Dermatology), which works in 15 minutes for itch relief. He noted its long-term efficacy, with 75% to 80% of patients not noticing eczema after using the cream. “It is going to remain our top drug for the adult atopic dermatitis patient,” Zirwas said.

Roflumilast and Its Efficacy in Seborrheic Areas

Next, Zirwas discussed roflumilast (Zoryve; Arcutis Biotherapeutics), which has recently received FDA-approval for atopic dermatitis.It has unique efficacy in seborrheic areas, making it particularly effective for scalp issues. Zirwas said while the foam formulation works well in atopic dermatitis, psoriasis, and other conditions, it excels in seborrheic areas.This, he said, is it what makes it a valuable addition to the treatment options for atopic dermatitis.

OX40 Drugs and Their Potential

As for pipeline therapies, Zirwas is excited about OX40 and OX40L drugs, which inhibit the interaction between antigen-presenting cells and memory T cells. “It's just really exciting to be able to say the words to patients, ‘This drug might retrain your immune system, so you essentially don't have eczema anymore,’” he said.

While these are only phase 2 results, Zirwas is excited to see the phase 3 findings and explore their potential for long-term atopic dermatitis remission.

In a second interview with Dermatology Times, Zirwas discussed recent scientific advancements made within the disease state.

To explore more of our coverage from Maui Derm NP+PA Fall 2024, click here.