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A Changing Treatment Landscape in Atopic Dermatitis


Raj Chovatiya, MD, PhD, and Lisa Swanson, MD, FAAD, review the recent trajectory of the atopic dermatitis therapeutic spectrum, notably how several newer approvals have changed how clinicians approach treatment.

Raj Chovatiya, MD, PhD: Hi, and welcome. We’re going to have a conversation about JAK inhibitors in atopic dermatitis. I’m Dr Raj Chovatiya, coming to you from Northwestern University School of Medicine in Chicago, Illinois. I’m joined by the inimitable Dr Lisa Swanson, coming to you from Idaho. I’m happy that we can sit down and chat about what’s been going on in dermatology. It’s been a crazy 5 years, hasn’t it?

Lisa Swanson, MD, FAAD: Has there been some new stuff, Raj?

Raj Chovatiya, MD, PhD: It feels as if it’s impossible to keep up with what’s going on, whether you look left or you look right. Before, when it came to atopic dermatitis, we didn’t have that much to talk about after some typical topical steroids. But now we have oral medications, topical medications, and injectable medications. The armamentarium is so rich. We’re going to focus on 1 of the most exciting advancements in the classes as far as treatment goes, JAK inhibitors. Lisa, maybe you can provide a broader perspective and more in-depth details about some of this expansion of our toolbox as far as treatment of atopic dermatitis.

Lisa Swanson, MD, FAAD: These are exciting times. I often say that we’re practicing dermatology during the golden age of dermatology, especially when it comes to inflammatory skin disease. Thank God, because for so long it was really hard to manage patients with moderate to severe atopic dermatitis, moderate to severe psoriasis, things like alopecia areata, vitiligo, and HS [Hidradenitis suppurativa]. We’ve really struggled.

When I’m giving talks to younger groups of medical professionals about some of the newer therapies, I’ll ask, “Is there anybody here that’s been in practice less than 5 years?” If anybody raises their hand, they don’t know how we struggled. We walked uphill both ways trying to manage moderate to severe atopic dermatitis without all the tools that we now have in our toolbox.

It started with dupilumab a little over 5 years ago. That cycle of new therapies will continue for years. I’m so grateful and thankful for it because I used to dread the follow-up visit with the horrible atopic dermatitis. Now, I don’t dread that at all. I’m like, “I have this that’s new, which we can talk about. I have this that’s new, which we can talk about.” It’s so nice to have options for these people who can be so miserable with their inflammatory skin disease.

Raj Chovatiya, MD, PhD: Your excitement is palpable. I couldn’t have put it better myself. Since the release of dupilumab—a monoclonal antibody that targets the IL-4 receptor alpha subunit that’s shared by IL-4 and IL-13, which we know is important to type 2 inflammatory signaling—we’ve seen some big changes. There was the launch of a new topical agent, topical ruxolitinib. There was a topical JAK inhibitor for mild to moderate atopic dermatitis. Then we saw an additional biologic therapy, tralokinumab, which specifically targets IL-13, 1 of the important signals in type 2 inflammation. Then we saw approvals for upadacitinib and abrocitinib. These are 2 oral JAK inhibitors targeting 1 of the important signaling molecules we think about across a lot of these signals for mild to moderate disease. We’ve seen so much advancement. The pipeline is so rich, so we’re going to have a lot to talk about.

In many ways, the way we think about atopic dermatitis has shifted a lot. Before, we had topical steroids. We’d go through the potencies and then maybe we’d jump up to something like methotrexate or cyclosporine, which work but with trade-offs. Beyond that, we’d have to throw our hands up in the air, saying, “I don’t know. This is the best we can do.” In many ways, that shifted my optimism for when I see my patients. When I see them, I’m saying, “I know this is a chronic disease. I know this is something that may wax and wane throughout your lifetime, but we’ve got options. If we don’t like the first or second option, then we’ve got third and fourth options.” You don’t have to feel as if you’ve exhausted all your choices as far as treatment goes.

Lisa Swanson, MD, FAAD: So true. Yes.

Transcript edited for clarity

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