'Stop Writing Systemic Corticosteroids for Atopic Dermatitis': Expanding the Toolkit for AD

"If there's one thing I can ask you to do today, it's to stop writing systemic corticosteroids for atopic dermatitis patients," said Christopher Bunick, MD, PhD, in a session at the 2024 Fall Clinical Dermatology Conference.

Bunick, associate professor of dermatology and translational biomedicine at the Yale University School of Medicine in New Haven, Connecticut, and Dermatology Times’ 2024 Winter Editor in Chief, joined colleagues Brad Glick, DO, MPH, and Alexandra Golant, MD, in a CME satellite symposium titled, "Is EASI 75 Good Enough or Can We Do Better? Elevating Efficacy and Long-Term Safety With JAK Inhibitors in Moderate-to-Severe Atopic Dermatitis."¹

During the session, Bunick emphasized that overreliance on corticosteroids is not only outdated but potentially harmful when better, more targeted therapies are available for atopic dermatitis (AD).

The Case Against Systemic Corticosteroids

One study presented by clinicians highlighted that about 20% of patients with AD are still receiving systemic corticosteroids, with 24% of these on long-term therapy. This usage contradicts the American Academy of Dermatology guidelines, which recommend against the long-term use of corticosteroids due to their potential adverse effects and suboptimal efficacy compared to newer treatments.

Research has shown that the adverse event rates associated with systemic corticosteroids—including malignancy—are significantly higher than those for alternative treatments like methotrexate and newer biologics. The TARGET-DERM registry, for example, highlights the pressing need for dermatologists to reassess their prescribing habits, especially when safer and more effective therapies are available.

"It's not the most efficacious, it's not the most safe, and we have a world with advanced systemic therapies, 5 of them approved, soon to be 6," Bunick emphasized. "You don't need this."

Challenges in Achieving Treatment Goals

The presentation also highlighted the concept of therapeutic inertia, where dermatologists may continue to prescribe a medication despite a lack of sufficient patient response. The panel noted that many patients are not reaching optimal treatment targets, with 30% to 40% failing to achieve desired outcomes.

"You have to be willing to know when to say this medicine isn't good enough for the patient and to move on," Bunick said. "I think the best way to do it is imagine you or the patient. Do you want your doctor to keep you on a medicine that isn't hitting optimal targets?"

The discussion moved toward the long-term efficacy of newer treatments, specifically oral Janus Kinase (JAK) inhibitors like upadacitinib (Rinvoq; AbbVie). Data from the Measure Up study indicated that 35% to 51% of patients experienced significant itch reduction and achieved EASI 90 by 140 weeks. Additionally, 74% to 85% of patients maintained EASI 90 after 140 weeks. Even those who reached moderate treatment targets after week 16 continued to show improvement, suggesting robust long-term efficacy for these therapies.

Switching to More Effective Treatments

The findings also included insights from the head-to-head study of upadacitinib versus dupilumab (Dupixent; Sanofi and Regeneron). Data indicated that at week 4, patients not achieving moderate targets could be dose escalated, leading to better outcomes. For example, among patients who switched from dupilumab to upadacitinib, 67% achieved EASI 75 within 4 weeks, and by week 32, 80% reached EASI 75. In contrast, only 9% of patients treated with dupilumab reached the benchmark by week 16.

Research indicates that the adverse event rates associated with systemic corticosteroids—including malignancy—are significantly higher than those for alternative treatments like methotrexate and newer biologics.²

Conclusions

Panelists concluded that the landscape of AD treatment is rapidly evolving, presenting dermatologists with a unique opportunity to improve patient care. By shifting away from systemic corticosteroids and adopting advanced therapeutic options, clinicians can better meet the needs of their patients and help them achieve optimal health outcomes.

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References

1. Bunick C, Glick B, Golant A. Is EASI 75 Good Enough or Can We Do Better? Elevating Efficacy and Long-Term Safety With JAK Inhibitors in Moderate-to-Severe Atopic Dermatitis. Presented at Fall Clinical Dermatology Conference; October 24-27, 2024; Las Vegas, Nevada.
2. Singh JA, Wells GA, Christensen R, et al. Adverse effects of biologics: a network meta-analysis and Cochrane overview. Cochrane Database Syst Rev. 2011;2011(2):CD008794. Published 2011 Feb 16. doi:10.1002/14651858.CD008794.pub2