Atopic Dermatitis Treatment: Past, Present and Future

In a seven-part Managed Healthcare Executive K-Cast video series (click here to view the series), Lawrence Eichenfield, M.D., chief of pediatric and adolescent dermatology at Rady Children’s Hospital-San Diego and a professor of dermatology at UC San Diego School of Medicine, discussed the current treatments for atopic dermatitis and the outlook for future therapies.

Treatment landscape and clinical burden

Over the past decade, new systemic therapies have been introduced, moving from a history of nonspecific immunosuppressive medicines to biologic agents and oral Janus kinase (JAK) inhibitors, Eichenfield said. The topical armamentarium has also changed with the addition of nonsteroidal medications to the traditional steroidal ones. Treatment choices have expanded because of an increased understanding of atopic dermatitis, its impact on people’s lives and its association with both traditional allergic or atopic morbidities and nonatopic illness, Eichenfield explained.

Lawrence Eichenfield, M.D.

The burden of atopic dermatitis is manifold, he continued. The rashes range from mild to severe. “Part of that clinical burden is the oozing, crusting, scaling and associated bleeding from scratching,” said Eichenfield, noting that the itch from atopic dermatitis can have a major impact on people, negatively affecting sleep and the sleep of others, especially if the person affected is a child. The clinical burden also includes the development of associated allergies, including food allergies, asthma, allergic rhinitis and some rarer conditions. Eichenfield said there are also psychological consequences, including anxiety and depression, especially with more severe atopic dermatitis. “In most studies, if you ask people to rank the burden of the disease, they list itch as No. 1. But in my experience, rash is probably just as important,” Eichenfield said.

Managing atopic dermatitis can get involved, which is another burden patients bear, he said. People are advised to bathe in certain ways, use moisturizers frequently and sometimes separate topical regimens for the face and the rest of the body. “It’s a lot of work that has to be done depending on the severity of disease,” Eichenfield said.

Overview of treatments

The usual strategy is to start with good skin care and bathing practices, including using a moisturizer after bathing, according to Eichenfield. If inflammation does not respond to moisturizers, the next step is anti-inflammatory agents, usually topical steroids.The first-line or second-line agents include calcineurin inhibitors, phosphodiesterase-4 inhibitors and a topical JAK inhibitor, Opzelura (ruxolitinib).

Eichenfield and his colleagues presented findings at the March 2024 American Academy of Dermatology Annual Meeting from a real-world effectiveness study of Opzelura that showed almost all of the 59 adult patients achieved clear or nearly clear skin within six months of therapy. More precisely, the average affected body surface area was reduced from 13.5%at the start of treatment to 5.7% (0%-20%) after treatment, and 62.7% (37 of 59 patients) had reduced disease severity, and 42.3% (25 of 59) achieved clear or almost clear skin. Physicians reported being satisfied with ruxolitinib cream monotherapy disease control for 91.5% of patients. Reasons to switch to ruxolitinib cream were loss of response/efficacy over time (33.3%), lack of long-term control (30.6%), patient requests (27.8%), and inadequate resolution of symptoms (22.2%).

Systemic therapy is the next step if more intense therapy is needed, Eichenfield said. Dupixent (dupilumab) was the first to be approved by the FDA. Originally approved just for adults, it is now approved for use in children and infants, Eichenfield noted. Other systemic agents mentioned byEichenfield include Adbry (tralokinumab); lebrikizumab, which is approved in Europe but not by the FDA; and two oral JAK inhibitors, Cibinqo (abrocitinib) and Rinvoq (upadacitinib). There are also traditional immunosuppressive agents, such as methotrexate, although they are no longer used as much because of the selective biological agents.

“My decision-making on which therapies to use, topical therapies or systemic therapies, very much starts with my messaging to patients and families, which is that what I’m going for is minimal rash, minimal itch and minimal sleep disturbance,” Eichenfield said.

Eichenfield said he considers how regional the atopic dermatitis is, the severity of the eczema quality and prior experience and responses to other medicines.

Eichenfield said the willingness of clinicians to use systemic therapy with the newer age of advanced systemic therapy is changing. He said that if someone has had an adequate trial of appropriate topical agents and there is inadequate control of signs and symptoms, “moving to a systemic agent right away certainly makes sense.” He cautioned that the use of systemic therapy in younger children is “still pretty new” and that very few children under the age of 2 were included in the Dupixent trials.

Navigating health insurance

Eichenfield said that the prior authorization process can be a lot of work. He said he has learned as a front-line clinician to document cases with regular body surface area assessments and global scores. In specialty clinics, he uses the Eczema Area and Severity Index.

Eichenfield said he also advocates at a regional and national level so managed care companies know “what we consider to be state-of-the-art therapy."
and don’t put unnecessary burdens on patients “getting medicines that we think are going to markedly change their lives.” Managed care organizations can implement reasonable evidence-based guidelines and best practices “by keeping their ear to the ground [and] having good personnel who are assessing what are considered to be the best therapies,” Eichenfield said. There are cost-benefit issues, he acknowledged. “But,” Eichenfield added, “in many cases, it comes down to if you had a family member with this disease state with this degree of severity … can they get the drug, and should they get the drug? If that’s the case, we want to facilitate that.” Eichenfield noted that it is also important to work with allergy, dermatology and pediatric dermatology professional organizations to ensure that their guidelines reflect the best practices.

Patient response

Following patients’ responses to therapy is part of good practice, said Eichenfield. Body surface area assessments can be done quickly, he said. Those assessments, along with global scores — if done routinely — can be helpful in underscoring successful responses to treatment for patients and, in pediatric cases, their families. Patients sometimes lose track of how bad their atopic dermatitis was before treatment, Eichenfield noted.

General questions are also important, in Eichenfield’s opinion. “ ‘How are you doing? How’s that itch? Is there sleep disturbance anymore? How’s the disease impacting your life?’ These are sort of standard questions that don’t take that long to do in every visit and follow-up for eczema patients,” Eichenfield said.

Clinicians also need to assess whether patients are experiencing any adverse events from medications, noted Eichenfield.

Looking ahead

Eichenfield said he is “incredibly proud” of the advances in understanding atopic dermatitis and the growing number of treatment options. There are still important questions that need answering, he said. “Probably the No. 1 question for me is, how will earlier therapy in the first few years of life impact the course of atopic dermatitis?” Eichnfield said. Some studies have suggested that introduction of treatment in the first few months of life might prevent atopic dermatitis or change its course and affect the development of food allergies. “I’m very excited about the next five to 10 years of atopic dermatitis research and how that translates into clinical practice,” Eichenfield said, noting that data on the new wave of systemic therapies are suggestive of notable remission rates and a scenario whereby treatment for a relatively short period might mean remission with no need for further treatment