Translating Evidence into Practice: Atopic Dermatitis Guidelines

This week, the American Academy of Dermatology Association Annual Meeting returns live and in-person in Boston, and for the session, “Translating Evidence into Practice: Atopic Dermatitis Guidelines,” a quartet of experts focused on recent developments in atopic dermatitis (AD) and how they affect clinical practice.¹ There have been promising AD treatments in the pipeline creating buzz over the last few years and that pipeline is full of exciting new advances to come.

The specific presentations were devoted to deciphering new associations and co-morbidities; providing understanding of the evidence behind newer therapies, particularly biologics; and showcasing clinical pearls that may slip between the cracks of the evidence.

Jonathan I. Silverberg, MD, PhD, MPH, FAAD, associate professor of dermatology at The George Washington University School of Medicine, in Washington DC, kicked things off discussing 2 broad topics—an AAD guideline update on comorbidities of AD and concepts of multimorbidity in AD.

Peter A. Lio, MD, FAAD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois, followed with a talk entitled, “On the Edge of Evidence.”

“My key message is that we should default to the highest level of evidence... but that 1 size may not fit all,” he said. “There is so much heterogeneity in our patients that until we can reach something closer to precision or personalized medicine, sometimes we need to think out of the box. That does not mean just doing something random. There are treatments and approaches that are at the edge of evidence, meaning there is some evidence that is, by definition, not high quality enough to be included in the conventional cannon as of yet, but may still be worth exploring.”

As someone who sees a great deal of severe AD patients, Lio is faced daily with patients who have failed everything and thus constantly searching for new approaches and therapies.

“I will say that some of the newer medications such as dupilumab (Dupixent; Sanofi and Regeneron Pharmaceuticals, Inc), tralokinumab [Adbry; Leo Pharma], upadacitinib [Rinvoq; AbbVie Inc], abrocitinib [Cibinqo; Pfizer], and topical ruxolitinib [Opzelura; Incyte Dermatology] have all proven to be extremely helpful for some of my patients and I am grateful to have more options,” he said. “We have made incredible strides in [AD], but we still have many patients with unmet needs. I often say that I need all the treatments I can get.”

During his talk, Lio discussed the importance of the skin barrier and how conventional moisturizers are key, but also how sunflower seed oil, coconut oil, and oral hempseed oil may offer additional benefits.

“I cover the microbiome and debunk, so to speak, the role of bleach baths, but also talk about how things like coconut oil and a bacterial endolysin enzyme could play a role in the future,” he said. “I also talk about itch and how cannabinoids may hold promise. Some of my favorite treatments cost little or no money and can be done at home without a prescription. While these almost never can fully replace prescription medications, they often can be used as complementary therapy and I truly believe can improve the quality of life for patients who are really suffering.”

There are challenges to what’s ahead, Lio said, including unmet needs for the patient, cost of medications, and access to care. Additionally, some medications have more adverse effects (AEs) and precautions that need to be discussed with patients. All of these can be significant barriers to care, he said.

“I’m hoping people walk away with some new ideas, an open mind, and a desire to keep pushing against that ‘edge of evidence,’” Lio sais. “For the session overall, I think we really want to give lots of broad updates on AD, with special focus on the new and emerging therapies and how best to think about them and utilize them in practice.”

The third speaker in the presentation is Andrew Blauvelt, MD, FAAD, president of the Oregon Medical Research Center, delivered a talk entitled, “New Therapies,” and concentrated on the many new drugs for AD that offer great new choices for patients with hope for better care.

“I [review] data on new topicals for AD such as ruxolitinib, roflumilast [ARQ-151; Arcutis Biotherapeutics], and tapinarof [Dermavant Sciences],” he said. “I also be [review] data on new systemic agents for AD—tralokinumab, lebrikizumab [Eli Lilly and Company], nemolizumab [Galderma], upadacitinib, abrocitinib and baricitinib [Olumiant; Eli Lilly and Incyte].”

As the leader of one of the prominent dermatology clinical trial unit in the United States, Blauvelt is well-versed on the newer developments and the problems that could occur.

“One should be cognizant of the safety issues associated with JAK inhibitors,” he said. “They need to be used with caution in certain populations.”

The biggest challenge with these, Blauvelt noted, is encouraging doctors to use new medications, and getting them to the patients when access is poor due to cost and insurance issues.

Robert Sidbury, MD, MPH, FAAD, division chief of dermatology at Seattle Children’s Hospital, concluded the session with a talk entitled, “The Rest of the Story,” where he covered additional developments in the AD space.

References:

1. Sidbury R, Blauvelt A, Lio PA, Silverberg JI. 2 Translating evidence into practice: atopic dermatitis guidelines. Presented at: American Academy Dermatology Association 2022 Annual Meeting; March 25-29, 2022; Boston, Massachusetts.