Utilizing Biologics in the Management of Moderate to Severe Atopic Dermatitis

“There is still much to learn [about atopic dermatitis] and shared decision making remains key in this complex journey,” said Peter Lio, MD, during the session “Closing the Health Care Gaps in the Management of Moderate to Severe Atopic Dermatitis (AD) With Biologics” during the 2023 Fall Clinical Dermatology Conference in Las Vegas, Nevada from October 19-22^.1

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Did you take our quiz about cytokines driving AD presented in this session? Test your knowledge!

Lio, MD, led the session alongside April Armstrong, MD, MPH, and serves as a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine and founding director the Chicago Integrative Eczema Center. Armstrong serves as the chief of the division of dermatology at UCLA Health and David Geffen School of Medicine at UCLA and chair of the medical board at the National Psoriasis Foundation.

The Burden of Disease in Patients

AD impacts 1 in 5 children and 1 in 10 adults, and one-third of children with AD develop allergy-related symptoms like asthma or hay fever. The biggest quality of life challenges for patients with AD include sleep disturbance, depression, anxiety, and suicidal ideation.²

“The itch-scratch cycle and skin tissue damage from scratching dysregulates cytokine and melatonin productions and circadian rhythm alterations, leading to maladaptive sleep behaviors and sleep interfering thoughts,” Armstrong explained.

Navigating the Patient Journey Through Atopic March

The complex pathophysiology of AD translates into a heterogeneous clinical presentation and trajectories of disease progression, and a significant proportion of children tend to develop persistent AD. Atopic march tends to affect those who have a family history of AD, severe AD early on, filaggrin mutation, live in an urban environment, and have polysensitization.³

Diving Into Case Studies

Armstrong and Lio walked attendees through moderate to severe AD cases and how biologics were integrated into treatment, including this case of an 18-year-old man describing very itchy, dry skin.

The man’s father noted that he constantly scratched, was up in the middle of the night, left bloody sheets from scratching so much, and was exhausted mentally and physically. The man and his father were upset that other clinicians keep prescribing triamcinolone. He first developed eczema patches as a baby and has had good periods, but lichenified plaques have been constant for the past few years. Beyond sleep issues, he was having problems in school. Current therapies other clinicians prescribed over the last few years included triamcinolone 2-3 times per day to the areas, pimecrolimus, crisaborole, and 50 mg of hydroxyzine morning and night.

In the consultation of this patient, Armstrong recommended clear communication of aggressive treatment not just with the patient’s father, but also the patient since he is 18 and forming his own identity, already burdened by the psychological impact of his AD.

Biologics Approved and in the Pipeline

Armstrong and Lio explained safety data behind biologics either already FDA-approved or pending approval.

• Dupilumab (Dupixent) targets IL-4 and IL-13 cytokines and is approved for patients 6 months and older. Adverse events reported in clinical trials included conjunctivitis, injection-site reactions, and a rare chance of arthritis.
• Tralokinumab(Adbry) targets IL-13 cytokines and is approved for patients 18 years and older. Adverse events reported in clinical trials included upper respiratory tract infections and mild, transient conjunctivitis.
• Lebrikizumab targets IL-13 cytokines and is pending approval for patients 12 years and older for >40 kg dosing. Adverse events reported in clinical trials included upper respiratory tract infection, nasopharyngitis, and conjunctivitis.

“The better understanding of the condition [AD] has brought new therapeutic options raising the treat-to-target goal higher than ever before,” Lio concluded.

References

1. Armstrong A, Lio P. Closing the Health Care Gaps in the Management of Moderate to Severe Atopic Dermatitis With Biologics. Presented at: 2023 Fall Clinical Dermatology Conference; October 19-22, 2023, Las Vegas, NV.
2. Weidinger S, Novak N. Atopic dermatitis. Lancet. 2016;387(10023):1109-1122. doi:10.1016/S0140-6736(15)00149-X
3. Irvine AD, Mina-Osorio P. Disease trajectories in childhood atopic dermatitis: an update and practitioner's guide. Br J Dermatol. 2019;181(5):895-906. doi:10.1111/bjd.17766