Caroline Nelson, MD: Biologics, JAK Inhibitors, Patch Testing for Allergic Reactions

During her latest HCPLive interview segment, Caroline Nelson, MD, highlighted when to use biologics or JAK inhibitors for allergic/non-allergic skin reactions and how clinicians should approach patch-testing for these conditions.

Nelson serves as the director of inpatient dermatology at the Yale School of Medicine. Her presentation was given at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2023 Annual Meeting in San Antonio, TX, and was called ‘Dermatology for the Allergist.’

She began with a discussion of biologics or JAK inhibitors’ use in managing skin reactions.

“So the primary way in which we make that distinction is in weighing out, I would say, 2 factors,” she explained. “First, the comorbidities of the patient. And second, whether the process is a very targeted immunologic process or whether it is a process that involves multiple components of the immune system.”

Nelson added that in her presentation, she referred to addressing psoriasis as an example of this distinction, for which a single IL-23 inhibitor like risankizumab may be appropriate.

“But when you're talking about something like a drug reaction with eosinophilia and systemic symptoms, you are activating multiple arms of the immune system at the same time,” she said. “You have a T cell response, you have an eosinophilia response, you have many wings of the immune system that are activated, and so you're generally going to need to select something that has more targets.”

Nelson also later described the use of skin biopsies for patients with these reactions, adding that the 2 types are shave and punch biopsies.

“So the choice between a shave and a punch skin biopsy is really based on the condition that you're interested in ruling out,” she said. “So, for example, if you are looking at a process like bullous pemphigoid…generally the action is happening at the split between the epidermis and the dermis. And so if you are doing a shave biopsy and you get an intact blister, you're going to be able to see that pathology beautifully.”

After elaborating more on biopsy use, she discussed patch testing for the management of allergic reactions.

“So, a lot of times even when I do suspect that a patient likely has adult atopic dermatitis, I will still send them for patch testing to rule out common triggers,” she said. “And frankly, also those (conditions that are) less common. I prefer to send to someone who has all of the extensive panels so that we really know on that first go, whether we're capturing a significant allergen that may be contributing.”

To find out more about Nelson’s AAAAI presentation highlights, view her full interview segment above.