Casey Butrus, PharmD: Dr. Keegan explains the treatment landscape for atopic dermatitis [AD] and the treatment categories and options available to patients.
Brian Keegan, M.D.: If you think about it, there are four main types of treatment that can be provided to patients. Bucket 1 is basic skin hygiene. This includes various emollients, topical over-the-counter medications, and skin barrier type products, avoiding anything that might irritate the skin. Patients have different experiences because many products are available for themselves through different outlets.
The second bucket is topical medications. They come in creams, tubes, and jars. Topical steroids are the ones we most commonly use, but there are also non-steroidal anti-inflammatory drugs that fall into several different category groups. Some prescription barrier creams are also available and patients may need our assistance to access those products.
The third bucket is phototherapy. Light therapy can help calm inflammation occurring in the patient’s skin. Some commented that whether the patient was a child and needed parental help or an adult and monotonous, treatment took longer. 15 minutes, 20 minutes, 30 minutes, and who wouldn’t want to spend the day with him? If the medication you have takes that long to apply, it can be difficult. Phototherapy and its ability to treat a larger body surface area can be very useful for some patients.
My fourth bucket is a full body treatment. When I started my practice many years ago, there was little or nothing I could offer my patients regarding specific unlabeled treatments. Everything we used was borrowed from various other specialties. In an effort to use other drugs to calm the immune system, fortunately many new molecules have been identified as injectables and pills. can be provided to the patient.
It is also possible to propose a combination of these. We can help someone choose the right type of skin hygiene product, but depending on their troubled area, benefit from topical, phototherapy, or a combination of topical and systemic treatments. Maybe. Fortunately, there are many new and excellent options to discuss, but the cost can make it very difficult for patients. What do you need to do to buy this or that, how much does a particular day or week cost, what products do you need, etc. Must buy, joint payment for coming to the office, etc. Michael probably wants to add a few things I forgot to mention about his approach to patient care.
Michael Cameron, MD, FAAD: It was a great summary. It’s an exciting time to treat AD. When I was in residency, our options were phototherapy, methotrexate, and dupilumab under the brand name Dupixent. It was generational therapy.The only generational therapy I saw in a dermatologist was Accutane [isotretinoin]Humira [adalimumab], and Dupixent.To generational, that is, completely changed the game. Since Dupixent came along, there have been other new biologics like Adbry [tralokinumab], was approved a year ago. Eli Lilly and Co will soon launch lebrikizumab. In the biological realm, it’s exciting.
In the oral small molecule arena, there are JAK inhibitors.There is upadacitinib [Rinvoq] and abrocitinib [Cibinqo], is an excellent oral small molecule that is highly effective. JAK safety, which I am passionate about, will eventually be discussed. But these are good systematic options.
In the topical realm, historically there have been no better alternatives.There was something like tacrolimus [Prograf], greasy and burned. I have a black box warning. We can debate the merits of that black box warning and whether it should be there, but it is. Then there was the less effective Elidel, or Pimecrolimus. Until the approval of crisabolol, we were restricted from a non-steroidal perspective. Recently, Opzelura, a topical ruxolitinib, was approved, so it is a topical JAK inhibitor. Non-steroidal treatments for atopic dermatitis have really improved, and one of the things he found that I’m interested in what Dr. Keegan said is that patients with atopic dermatitis are more likely than, say, those with psoriasis. are reluctant to use steroids. do you agree?
Brian Keegan, M.D.: Agree. Some are age related. Many parents are very reluctant to use topical steroids on their children.
Michael Cameron, MD, FAAD: Steroid rebound, steroid resistance, and steroid thinning are a constant concern for long-distance and even adult patients, partly due to age. Much more than people with psoriasis. It’s exciting to see more non-steroids coming to market, hopefully soon. Recently approved for psoriasis, but with good data in the eczema population. We saw phase 3 data from the topical roflumilast, Xoliev, and some impressive data from tapinarov. [Vtama]Also approved for psoriasis. Hopefully we’ll have it in the eczema population soon.
Casey Butrus, PharmD: That brings us back to your point about the inflammatory nature of atopic dermatitis and psoriasis vulgaris, both chronic inflammatory diseases. It will be interesting to see soon.
Edited transcript for clarity.