Optimal Sequencing of Therapy for Atopic Dermatitis


Taking into account all available topical and systemic therapies, Marc Serota, MD, provides his optimal sequencing strategy for patients with atopic dermatitis.


Marc Serota, MD: This is a very, very important question [about sequencing of therapies]. I’ve said the previous decade of the dermatology specialty was all about psoriasis innovation, and the next decade is all about atopic dermatitis innovation. We’re starting to see more and more of that now with these therapies that have been developed and now are FDA approved and on the market. I think first it’s important to stratify, in general, the severity of the patient, whether they’re mild, moderate, or severe.

I think establishing if they’re mild versus moderate/severe is probably the most important designation because if they’re mild, you’re probably going to be recommending topical therapies to start with. Whereas if they’re moderate or severe, I advocate discussing systemic therapies with the patient and deciding together if that’s the right option for them.

I would typically start with either a steroid and/or a nonsteroidal option. I think having some nonsteroidal options; traditionally we had low potency all the way up to super potent topical steroids, but there has always been some fear associated with applying very potent steroids, especially to sensitive skin areas like the face. When it comes to topicals, my typical approach is if they just have their body affected, I will prescribe a medium potency topical steroid plus or minus a low potency steroid for the face. That was traditionally how I did it.

Now, we have 2 nonsteroidal options that are relatively new. One is a phosphodiesterase-4 inhibitor called Eucrisa. The issue with Eucrisa had been that there is some burning and stinging associated with it, which prevented a lot of doctors and patients from wanting to use it. Then more recently, a topical JAK inhibitor called Opzelura [ruxolitinib] has come out, which has shown very promising efficacy and lacked the burning and stinging. If you have a patient who just wants 1 tube of 1 thing, I really like the Opzelura option because they can use it on their face. They can use it on stubborn areas of their bodies, and it’s generally very well tolerated.

Once you talk about systemic therapies, there are 2 main categories. There are the biologic therapies, and then there are the newer JAK inhibitors. The third category would be the traditional immune suppressants. That is the order in which I think of them. I think of the biologics as my first-line systemic therapy, dupilumab being the main one, which blocks IL-4 [interleukin-4] and IL-13. Then we have tralokinumab, which is newer on the market and just blocks IL-13.

What’s the difference? IL-4 plays a critical role in the initial differentiation of TH2 [T helper cell type 2] cells. What does that mean? That means a naive T cell turns itself into the allergic cell general and turns on this allergic cell pathway. The other advantage dupilumab has is it’s approved down to age 6 and it’s approved for the 3 atopic conditions that we see together frequently, which are: atopic dermatitis; asthma, also down to age 6, moderate to severe; and rhinosinusitis with nasal polyps, [ages] 18 and over. Tralokinumab is approved for [ages] 18 and over for atopic dermatitis.

Then we have the JAK inhibitors, which I sequence behind the biologics; 1, because they’re newer; 2, because they have black box warnings, and the safety profile suggests to me that I would use them as second-line therapies if the patient did not respond to the biologics or they weren’t a good a candidate.

Some patients will be candidates for first-line therapy with the JAK inhibitors, particularly if they want a pill, that’s the big advantage. Their efficacy is very good. They work very quickly, and they have the advantage of being a pill over an injection.

Then third would be the traditional immune suppressants. That’s how I stratify when I’m thinking about systemic therapies in general, but then you always want to tailor it to the specific needs of the patient.

Transcript edited for clarity.

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