Acne 

Actinic Keratosis 

Aesthetics

Alopecia

Biologic Treatments for Moderate to Severe Atopic Dermatitis 

Atopic Dermatitis 

COVID-19

Drug Watch

Eczema

General Dermatology 

Hidradenitis Suppurativa

Melasma

NP and PA

Pediatric Dermatology

Pigmentary Disorders 

Practice Management 

Precision Medicine and Biologics

Prurigo Nodularis

Emerging Therapies Plaque Psoriasis

Treatments for Plaque Psoriasis 

Psoriasis 

Psoriatic Arthritis 

Rare Disease

Rosacea 

Skin Cancer (Nonmelanoma)

Skin Cancer

Vitiligo

Wound Care

News

Media

Around the Practice

Between The Lines

Case-Based Peer Perspective

Clinical Case Collective

DermView

Expert Perspectives

Fellows Face Off

Frontline Forum

Medical World News

Patient Perspectives

Podcasts

Readout360

Recognize and Refer

Conferences

Conference Coverage

Conference Listing

Events

Case-Based Roundtable

Publication

Dermatology Times

CME/CE

Resources

DermIQ

Interactive Tools

Job Board

Partner Perspectives

Polls

Editorial Advisory Board

Partners

Subscribe

Maddi Hebebrand is an associate editor of 

and joined the MJH Life Sciences team in May 2024. She attended Baldwin Wallace University, studying Media Production and Film, and is now finishing her Masters in Digital Media through Ohio University. When she's not writing, Maddi loves to read, attend concerts and spend time with her family.

Articles

While researchers found both therapies effective in long-term use, they stated secukinumab showed quicker improvements in QoL.

GPP Therapies: Comparing Efficacy and Safety of Secukinumab and Ustekinumab

Eric Simpson, MD, MCR, FAAD, lead author of a recently-published article highlighting roflumilast cream 0.15%, joined us for a Q+A interview.

 Q+A: Roflumilast cream 0.15% for AD with Eric Simpson, MD, MCR, FAAD

and joined the MJH Life Sciences team in February 2023. She attended Kent State University and earned a Bachelor of Science degree in journalism with minors in public relations and creative writing. She enjoys making and listening to music, reading, and spending time with her cats, Astrid and Marceline.

More than half of treatment responders maintained stable EASI ≤ 7, according to a poster from EADV.

Significant Proportion of Patients With AD Maintain Stable EASI With Tralokinumab Treatment

A poster presented at EADV 2024 explored patient-reported outcomes from. the TRACE study for AD.

9 Months of Treatment With Tralokinumab Results in Improved QoL, Itch, and Sleep

About

Advertise

Contact Us

Do Not Sell My Information

Terms and Conditions

Privacy Policy

Dermatology Times and Multimedia Medical, LLC

Twitter

Facebook

Linkedin

Topics

Acne

Pigmentary Disorders

Practice Management

Psoriasis

Psoriatic Arthritis

Rosacea

1rem

Authors

Patricia Richey, MD, delves into efficacy of the 1927 and 1550 nanometer lasers to prevent skin cancers.

The Role of Laser Treatments in Preventing Skin Cancer

Final Thoughts: The Importance of Comparative Studies in AD

Panelists offer concluding insights and emphasize the critical role of comparative studies in advancing atopic dermatitis treatment strategies.

clinical

Video Series

Ruth Ann Vleugels, MD, MPH, MBA, delves into patient-specific considerations and action plans when on a JAK inhibitor.

Other Treatments to Incorporate With JAK Inhibitors

This news content has been independently developed and is not endorsed by the American Academy of Dermatology.

 Expert Perspectives series delves into the multifaceted landscape of atopic dermatitis (AD) care and treatment. Through interviews with 4 leading dermatologists, this series explores key benchmarks, emerging trends, personalized medicine approaches, long-term safety considerations, and the integration of novel therapies in the management of AD. Each episode provides valuable insights into navigating the heterogeneity of AD presentations, selecting appropriate treatment plans tailored to individual patient needs, and incorporating the latest guidelines from the American Academy of Dermatology. From discussing the nuances of patient education and shared decision-making to addressing the intersection of comorbidities with AD management, this series equips dermatology clinicians with the knowledge and strategies necessary to optimize patient outcomes and enhance the quality of care.

In this episode, Ruth Ann Vleugels, MD, MPH, MBA, dermatologist at Brigham and Women’s Hospital and Boston Children’s Hospital in Boston, Massachusetts, delves into patient-specific considerations and action plans when on a JAK inhibitor, including shingles prevention and management.

Dermatology Times Interview with Ruth Ann Vleugels, MD, MPH, MBA

What steps do you follow when first starting a patient on a JAK inhibitor?

 When we're first starting JAK inhibitors on a patient, one of the things that you want to think about is giving a patient 1 dose of the varicella-zoster gE-AS01B (PF) vaccine or Shingrix prior to starting JAK inhibition. Now, keep in mind, patients need 2 doses of that vaccination, but since it's a killed vaccine, we're totally fine giving them their second dose after they've already been on therapy with JAK inhibition. But that's something to remember to reduce the patient's risk of shingles after they start JAK inhibition. When you're considering Shingrix vaccination, I feel like many of my dermatology colleagues recall that traditionally that vaccine was recommended when patients are 50 years or older. But really interestingly, the CDC actually a couple of years ago changed those guidelines and they actually reduced that age down to 18 if the patient is going to be on an immunomodulatory or immunosuppressive therapy, in order to decrease their risk of shingles. So now actually, not only can we recommend it in patients who are 18 and over, but in addition to that, we can also get insurance coverage for our patients. So it's not challenging to get a Shingrix vaccination.
Let's say you have a 36-year old you want to start on a JAK inhibitor for AD. Clearly these are patients who have AD and that need treatment. Often they have moderate to severe skin disease. They have itch. The nice thing about JAK inhibitors is we can tell them that they're going to notice benefit very quickly, because thankfully, these are agents that work rapidly and the nice thing about that is is patients then feel invested in their treatment. So whenever we're starting a patient, we do want to talk about risks of medications. And of course, we're going to speak about things that can come up in patients such as shingles, which is why we already spoke about the fact that we're going to give them a Shingrix vaccine before they start. And then we're actually going to talk to them about the fact that these medicines have been around for quite a while, and so we're very comfortable with their side effect profile. We're going to make sure we select the right patient and ask them some questions to ensure that they're a great candidate for this therapy. And then I often will remind them that the initial data that the long-term safety was done in these patients was done in our patients who have rheumatoid arthritis. So this is a very different disease in our patients with AD. Our rheumatoid arthritis patients tend to be older and, at baseline, they have a higher risk of some things that we saw in the long-term safety data using our initial JAK inhibitors for our patients with arthritis. So those are the patients in which we saw an increased risk of blood clots, cardiac events, and cancer. And in fact, when we look at our longer term safety data with upadacitinib, for example, or other JAK inhibitors, we don't see that same side effect profile as we did in our initial rheumatoid arthritis dose patients.
I think that's an a really important distinction for my dermatology colleagues to understand in AD patients. The rates of these are similar to background, so again, I'm still going to ask my patients about risk factors for those comorbidities and then modify their risk factors and help them if they have any of those. I'm going to feel comfortable using a JAK inhibitor when I need it for AD, given their high efficacy, rapidity of onset, and overall safety profile.

Ruth Ann Vleugels, MD, MPH, MBA, delves into patient-specific considerations and action plans when on a JAK inhibitor, including shingles prevention and management. 

Ruth Ann Vleugels, MD, MPH, MBA, shares insights that she gives her own residents on JAK inhibitor selection, risks, benefits, and data available. 

JAK Inhibitor Selection Considerations

In this episode, Ruth Ann Vleugels, MD, MPH, MBA, dermatologist at Brigham and Women’s Hospital and Boston Children’s Hospital in Boston, Massachusetts, shares insights that she gives her own residents on JAK inhibitor selection, risks, benefits, and data available.

What factors do you take into consideration when prescribing JAK inhibitors for AD?

 When I use JAK inhibitors for AD, I always want to really think about my patient selection. I think that's the most important point when you're trying to decide whether to use a JAK inhibitor for AD because they're fantastic medications. They work really quickly. They have high efficacy. And so really, what I want to think about is: Who's the correct patient? 

So when we're doing that, we actually ask patients if they have any history of cancer, and we ask them if they're up to date on their current cancer screening. We also ask patients about any history of clotting or current tobacco use. We ask patients about cardiac risk factors. Then, our job is going to be to modify those risk factors just like we would with any other our other patients on systemic therapies. And as long as I pick the appropriate patient, I feel very comfortable treating patients long-term with JAK inhibitors. 

I'm very fortunate because I've lived in the dermatology/rheumatology world for a large chunk of my life. And it's good to remind ourselves that we've actually been using JAK inhibitors since 2012 for many of our diseases. So when we're talking to our patients, we often want to remind them that although these drugs were more recently approved for their AD, we've actually been using these medications for well over a decade and for many other indications as well. During extended treatment periods with JAK inhibitors, we do want to follow laboratories and our patients. 

Typically once a patient has been on a JAK inhibitor for a few months, we're just monitoring their labs quarterly, and so many of those labs we're following as we would in any patient on systemic therapies, include blood counts, liver tests, kidney function tests. Then, we always want to monitor their lipids as well. These are things that I'm going to be addressing on a quarterly basis and ensuring that they're all normal, and if anything changes, address those as I would in any patient on a systemic medication. Most of the time, their labs are actually normal on JAK inhibition, but it is something we check quarterly to ensure that they are in every patient we're treating. 

When we're selecting a JAK inhibitor, often we're driven by what's on label for the particular disease, and thankfully, we have more than 1 JAK inhibitor approved for AD. So for many years, we've been using JAK inhibitors off label for AD, particularly in our patients with more than 1 inflammatory or autoimmune disease, and we knew that they were effective, but thankfully now we have FDA approval for our patients and often we're reaching for a JAK, in particular, in patients who have moderate to severe disease and also in those patients where we need improvement because we know these therapies are really phenomenal in reducing our patients' itch. We know often, even when their disease looks a lot better, they can still have residual pruritus, which interferes with their sleep and interferes with their daily activities. So another reason we're often reaching for JAK inhibitors is to help reduce that residual itch, and also rapidity of onset. 

What are the major advantages of JAK inhibitors for AD?

 So thankfully, JAK inhibitors have very rapid onset of action. One of the things I like to highlight when I'm teaching my residents is the fact that, rather than reaching for prednisone, which is often what dermatologists have done in the past, because it can act as an off switch for AD and works very rapidly, we can actually reach for an agent like a JAK inhibitor and completely bypass prednisone which has such such substantial risks for our patients. When we're using JAK inhibitors for AD, one of the advantages is that we have once-a-day dosing, so that's a huge advantage for our patients to improve adherence. The other thing that really helps is that, because of their rapid onset of action, patients can tell within a couple of days often that they're having benefit from their therapy. So it's really interesting because even within 1 to 2 days of medication, they often will notice that they're actually starting to improve and that also is really helpful in getting patients to adhere to their medicine. So long-term adherence with JAK inhibitors is something that is made more simple by the fact that we have once-a-day dosing and they have rapid onset of action. But of course, whenever we see our patients, we're always talking about how often they're able to take their medicine. We know that to some degree for all of our patients on on any medication. Adherence can be a challenge, but these particular characteristics of JAK inhibitors clearly make adherence more palatable in our AD patients than many of the other therapies we have.

Mark Lebwohl, MD, discusses the rapid expansion of therapeutic options, including targeted drugs like JAK inhibitors and IL-13 treatments for atopic dermatitis.

Expanding on Atopic Dermatitis Triggers and Comorbidities, and Advancements

 Expert Perspectives series delves into the multifaceted landscape of atopic dermatitis (AD) care and treatment. Through interviews with 4 leading dermatologists, this series explores key benchmarks, emerging trends, personalized medicine approaches, long-term safety considerations, and the integration of novel therapies in the management of AD. Each episode provides valuable insights into navigating the heterogeneity of AD presentations, selecting appropriate treatment plans tailored to individual patient needs, and incorporating the latest guidelines from the American Academy of Dermatology (AAD). From discussing the nuances of patient education and shared decision-making to addressing the intersection of comorbidities with AD management, this series equips dermatology clinicians with the knowledge and strategies necessary to optimize patient outcomes and enhance the quality of care.

In this episode, Mark Lebwohl, MD, dean for clinical therapeutics at the Icahn School of Medicine at Mount Sinai in New York, New York, discusses the rapid expansion of therapeutic options, including targeted drugs like JAK inhibitors and IL-13 treatments for atopic dermatitis, paralleling the progress seen in psoriasis treatment over the last decade.

Dermatology Times Interview with Mark Lebwohl, MD

In your experience, what are the most common stimulants of AD?

 So there are a number of very specific triggers for AD. For example, a patient who comes in and tells you that they're bathing 3 times a day, you know that that's excessive, and that will be exacerbating their AD. So something as simple as reducing the frequency of bathing using gentle soap substitutes and using moisturizers might be adequate for those patients. Patients will often tell you that they get worse during the wintertime because cold dry air and steam heat dry out their skin. Again, reducing bathing and using more moisturizers may be helpful to those patients. Other patients will tell you that they get worse after exercise or in the summertime because sweat is a factor. Something as simple as air conditioning may help those patients. So identifying the factors that trigger AD in particular patients should have a direct effect on the treatments that you suggest.

What are your biggest considerations when choosing AD therapies?

 Comorbidities may have a direct effect on the treatments that you select for patients. So for example, if a patient happens to have asthma as well, we have treatments such as dupilumab (Dupixent), which effectively treat both the AD and the asthma. There are other comorbidities such as osteoporosis, for example, that have been reported in patients with AD. So that gives you yet another reason to avoid the use of systemic steroids in those patients. And there are a whole host of other comorbidities that impact the disease. If patients have complications of other treatments, for example, striae because of excessive use of topical steroids. Then, we finally have, non-steroids that we can go to that are very effective for the topical therapy of AD without having the risk of stretch marks or cutaneous atrophy. So, again, many of the comorbidities have to be considered when you are picking the best treatment for a patient with AD.
There are many new diverse treatments that are highly effective for AD, regardless of severity. So for example, we have new topical therapies that are non-steroids, ones already on the market recently introduced ruxolitinib (Opzelura) cream. There are 2 additional ones tapinarof (Vtama) cream and roflumilast (Zoryve) cream that are on the way. They've completed their early phase trials. So in the realm of topical therapy, we have a lot of breakthroughs. In the realm of systemic therapy, we also have a lot of breakthroughs. There are also additional therapies on the horizon for chronic hand dermatitis, which is a form of AD delgocitinib cream, which hopefully will be available in the United States sometime soon. We also have many new top systemic therapies for AD. We've had dupilumab for a number of years already. Coming hopefully soon, we'll be lebrikizumab (Ebglyss). We already have tralokinumab (Adbry). These block IL-13, so they're a little bit more targeted than dupilumab and comparably effective. We have JAK inhibitors that have been introduced specifically, upadacitinib (Rinvoq) and abrocitinib (Cibinqo), which are already approved for AD. Several others certainly have been studied for AD.

What therapies are you most excited about with recent approval or in the pipeline?


 Our therapeutic armamentarium for the disease has grown very quickly and looks like it will continue to grow. There are a number of additional anti IL-13 drugs on the horizon. Also drugs that target OX40 antibodies, which appear to be promising for AD. So I think we're going to experience in AD what we have experienced in the last decade for psoriasis where we have an explosion of new, better, safer treatments that help our patients live better lives.

Mark Lebwohl, MD, discusses the rapid expansion of therapeutic options, including targeted drugs like JAK inhibitors and IL-13 treatments for atopic dermatitis, paralleling the progress seen in psoriasis treatment over the last decade.

Mark Lebwohl, MD, emphasizes the importance of considering various factors when determining treatments for patients with atopic dermatitis

Understanding The Heterogenous Nature of Atopic Dermatitis 

In this episode, Mark Lebwohl, MD, dean for clinical therapeutics at the Icahn School of Medicine at Mount Sinai in New York, New York, emphasizes the importance of considering various factors, including severity of itch and interference with sleep, when determining treatments for patients with AD, even with presentation may not include typical symptoms.

 AD is a heterogeneous group of diseases. Now that we have treatments, we know how heterogeneous it is because all of the conditions that are part of what has been called the atopic complex, are treatable with medications like IL-4 and IL-13 inhibitors. For example, idiopathic pruritis responds beautifully to an IL-4 blockade. Nummular eczema, hand dermatitis, dyshidrotic eczema, and prurigo nodularis are all manifestations of this heterogeneous group of diseases that we call AD.
When managing AD, it's very important to look at a number of factors such as severity of disease. If it is extensive, topical therapy is not going to be adequate. If it is severe and not responsive to topical therapy, then of course, it would be. So, severity of disease is one of the most important factors.

What do you consider from patient to patient? 

There are a number of other factors that have to be considered. I always ask the patient if they get worse in the summer or the winter. So turns out many patients are worse in the wintertime. And for them, things like humidifiers. moisturizing, and reducing excessive bathing might be helpful. In the summertime, sweat is usually an exacerbating factor and air conditioning is important. So all of those factors have to be considered when taking care of patients with AD. Severity of itch and interference with sleep for example, is another important factor. If a patient is itching so severely that they can't sleep, that would justify moving to a more aggressive therapy.


Mark Lebwohl, MD, emphasizes the importance of considering various factors, including severity of itch and interference with sleep, when determining treatments for patients with atopic dermatitis, even with presentation may not include typical symptoms.

Christopher Bunick, MD, PhD, expands on how clinicians can personalize treatment plans for each patient.

Personalizing Treatment Approaches For Each Unique Patient 

In this episode, Christopher Bunick, MD, PhD, of Yale University in New Haven, Connecticut, expands on the current treatment landscape for atopic dermatitis and how clinicians can personalize treatment plans for each patient.

Dermatology Times Interview with Christopher Bunick, MD, PhD

What have been the biggest advancements in AD treatment in your time in dermatology?

 Since I finished residency in 2012, at that time, we really didn't have a lot of great therapies for AD. We relied on traditional immunosuppressants to try to help our AD patients or systemic steroids or lots of topical agents. And it has been amazing over the last decade to watch new therapies come. The first therapy was dupilumab, and it really did change the way and revolutionize how we treat AD patients. And now, we have other biologics like tralokinumab. We have others coming [like] lebrikizumab. We have others in develop development beyond that nimolizumab is on the horizon. So it's been really nice to have a set of biologics to treat these patients.
What we didn't expect in dermatology was the bombshell of small molecules like JAK inhibitors completely take what we thought was the best standard of care for patients and upended and do even better. And that's really been the surprise, I think, over the last 2 to 3 years in dermatology. It has been this entire upheaval of benchmarks, this entire upheaval of what we thought was possible for getting different diseases better and AD is a great example of that, where we're seeing the we're seeing the JAK inhibitors really push that boundary. Now they are complementary to the biologics. And I think that what's really great and in the end, it's all about the patient. And what's really great for the patient is that they have a lot of options. They're pushing the boundary in terms of efficacy. They're pushing the boundary in terms of speed of onset, durability, and even safety.
What we need in dermatology is to have, especially in AD, where it's a very heterogeneous disease. What I mean by that is AD, historically, we've thought about it primarily as an IL-4 or IL-13 mediated disease, but we have learned that it's much more heterogeneous than that. There are other cytokines that definitely play a role, and not every AD patient is the same. This is why we need multiple therapies because there are multiple different types of AD patients and different therapies may work differently in those patients. So having the biologics, having the JAK inhibitors is very helpful. Now, one of the advantages of the JAK inhibitors is it hits multiple cytokine pathways, and I think that explains or ties in these benchmarks that we've been talking about. It ties in these higher efficacy standards and quality of life standards. That's probably why the JAK inhibitors are doing so well is because of their ability to broadly inhibit the cytokines involved in AD pathogenesis. And as they're inhibiting the cytokines, they're doing it within the cell. Right? They're not working outside the cell. They're working inside the cell. And this is important because that's where the JAK stat proteins are being activated to go in and regulate transcriptional machinery. And so this is really, partly why the JAK inhibitors are working really fast is because of that direct action inside the cell.


Outside of systemic therapies, what other treatments (both approved and in the pipeline) are you excited about?

 There is a place for topical therapies in AD as well, and what we've really learned over the last couple of years is that there's a high demand for nonsteroidal topicals. We've used steroids for a long time, but there's a limit of what you can do in pediatric patients. There's a limit what you can do in adult and adolescent patients. And one of the great things is that we have now a lot of innovation in terms of nonsteroidal topicals. And so for example, we have had for a while, that PDE4 inhibitor, crisaborole, which is out there, and it has helped patients, but we have newer innovation. We have a new generation PDE4 inhibitor that's on the verge of approval roflumilast, for AD. We have a new aryl hydrocarbon agonist, on the verge of approval on AD in tapinarof. We have already approved a JAK inhibitor ruxolitinib for topical use in AD. This is really exciting because these topicals in particular, the one that's approved, ruxolitinib, is really changing the game in treating localized AD disease, because we're able to now use medicines like the JAK inhibitor ruxolitinib that works highly efficaciously, is very quick, and it's comfortable for children and for patients or parents to understand that this is not a steroid. They're more willing to use that type of topical medicine.
We're only going to see the nonsteroidal options increase in the coming months and year and this is, again, a really exciting development for AD patients. The AD patient is unique. Each patient is unique. There is a component of shared medical decision-making that's going to be needed. You have to talk to your patient, understand where they're coming from, and what their need is. We know that AD is a heterogeneous disease. And what we mean by that is the underlying molecular pathophysiology of AD is not the same in every subgroup of patient. So we do have to take into account that variability, that heterogeneity, may mean that different treatments are going to be needed for different patients. For me, I think one of the most important things that I do is I try to get my patients on an advanced therapy early. I asked how much that AD is affecting their quality of life, that connection between skin disease but also how it's affecting them in school, in the workplace, or in their social life. To me that's really important, because it allows me to then communicate with the patient what I think can really be transformative for their AD treatment. I really focus in on the degree of itch, disturbance and the degree of sleep disturbance.

 If any of the itch or sleep is high, I really have an honest discussion with my patients about advanced systemic therapies, which at the current moment, involves 2 biologics, dupilumab and tralokinumab, and 2 oral systemic JAK inhibitors, upadacitinib and abrocitinib. And I review those 4 with my patients and there's going to be newer agents coming that's going to make the discussion even more broad. However, at the moment, I have that discussion with my patient. I try to figure out what goals the patient wants from their treatment.
Do they want really fast resolution of their itch and skin? In those cases, the JAK inhibitor might be a great option. Does the patient have concomitant asthma? In that case, dupilumab might be a great option. Has the patient tried a prior biologic or a prior agent and failed that agent? We know that if we know from the past 6, 7 years of lots of patients with severe AD going on dupilumab, that not every patient responds perfectly to that medicine. So how are they biologic naive? Or are they biologic experience? Because if they've tried a biologic and not done as well as they wanted, an oral JAK inhibitor makes a lot of sense. I've also had patients that have failed dupilumab and have done very well with tralokinumab. So there are options out there. But in general, having that desire or understanding of what the patient wants in terms of skin clearance, rapidity of results, and how to get the patient back on their feet and back in their lives quickly, I think that understanding the JAK inhibitors and having a discussion with your patient about them is really important.

Patricia Richey, MD, FAAD

Articles

Latest Updated Articles