Matthew Zirwas, MD: How Tapinarof Could Address Adult-Onset Atopic Dermatitis

Reports have indicated global atopic dermatitis prevalence has been relatively stagnant for the last 2 decades. However, collective research into what drives adult-onset atopic dermatitis—combined with the realities of aging populations in nations like the US—lead to worry that cases may climb still, and methods to mitigate different iterations of the disease will be needed.

In the third segment of an interview with HCPLive during the Maui Derm 2023 NP + PA Summer Conference in Colorado Springs this week, Matthew Zirwas, MD, director of the clinical trials and dermatitis center at Dermatologists of Greater Columbus, discussed the relatively recent discoveries into disparities between adult-onset and childhood-onset eczema. Collective epidemiologic, pathophysiologic, genetic, and treatment-response data has led to a firm understanding as to what differentiates disease onset timing.

“In kids, it is a genetic disease of barrier deficiency,” Zirwas explained. “In adults, it’s also a barrier deficiency—but it’s not genetic—it’s due to the long-term, low-grade exposure to environmental damage.”

Zirwas said data show a combination of factors—air pollution, hard water, and even surfactants including soap and some detergents—may accumulate increased risk of atopic dermatitis in adults who don’t even have a genetic disposition for the disease.

“These are causing epigenetic changes in your keratinocytes that are slowly degrading your barrier,” Zirwas said. “We now think of this the same way we think of field cancerization in skin cancer.”

On the subject of preventive strategies, Zirwas said some non-medicinal strategies may help reduce risk.

“Some of it is impossible…but you could move from busy roads,” he said. “You could use a laundry detergent that has very low irritant surfactants. You could stop using soap on most of your body. We can start to do things like that to reduce the likelihood of getting it.”

Rather, Zirwas is particularly excited about the prospect of topical tapinarof—a drug he has been involved in research with himself—and its potential role in managing adult-onset atopic dermatitis on the basis of these discoveries.

“What makes it unique in psoriasis is this big remittive effect,” Zirwas said. “What I have seen so far is a strong remittive effect in adult-onset atopic dermatitis, but not so such a strong remittive effect in childhood-onset atopic dermatitis.”

With a “totally unique mechanism of action” relative to other JAK inhibitors, tapinarof essentially leads the skin to homeostasis, Zirwas said—it cannot alter a person’s genetic barrier deficiency. “But if you’re an adult capable of making (the barrier)…I think we’re going to find tapinarof restores that barrier and then keeps it restored.”