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Adolescents Versus Adults: Considerations for Hand-Foot Atopic Dermatitis

Opinion
Video

Peter Lio, MD, expands on dosing considerations to treat atopic dermatitis with involvement on the hands and feet for different ages, weights, lifestyles, and more.

In the Dermatology Times Expert Perspectives series "Advancements in Atopic Dermatitis: Insights from the 2024 Masterclasses in Dermatology Conference," leading dermatologists discuss the advancements in treatments and data for atopic dermatitis (AD) with hand-foot involvement, diversity in clinical trials, and pearls from the American Academy of Dermatology's AD treatment guidelines.

Earlier this year, the US Food and Drug Administration approved an update to the label for dupilumab (Dupixent) in AD, specifically addressing patients aged 12 years and older with uncontrolled moderate to severe hand and/or foot involvement. The label update is based on findings from the phase 3 LIBERTY-AD-HAFT trial, a double-blind, placebo-controlled study involving 133 adult and adolescent patients with AD and moderate to severe hand and/or foot involvement.1

In this episode, Peter Lio, MD, clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois, expands on dosing considerations tailored to each patient depending on their age, weight, lifestyle, and more.

Episode Transcript

Lio: I think between adolescents and adults, there's nothing directly that I would do differently, but for all of the patients in this group, the most important thing is asking about their quality of life and their function, because even if it looks pretty good on my exam that day, that does not necessarily mean that they're where they need to be. You might come in on this particular Wednesday in the office, it looks okay, it looks like they're pretty healed, but they might say, "Dr. Lio, it's been terrible the last few weeks. I've had cuts and fissures. It has been painful and I'm having trouble using my hands." So, that functional piece is really what distinguishes hands and also feet, of course, from the rest of the body.

I think we understand that, in general, most of the outcome measures run together. If we see clear, almost clear, if we see a significant improvement in itch, all of those tend to follow each other and that tends to bring with it an improvement in quality of life, but it is not perfect. So I really do think we have to ask those questions to each patient and explain the different aspects. For some people, the itch is the main thing driving them crazy and that's kind of all they care about. That's going to be what's most tied to their outcome and their happiness. To other people, it's the appearance. And to most patients, I really think it's a combination. So I'm asking about all of those things. I want to ask them how it's looked and felt. I want to ask them about the itch. And then I also want to ask what kind of functional outcome it's had.

But when we're talking a bout the different options, we're always weighing this in the shared decision -making process. We're talking about: what are the risks? What are the potential benefits? What are the accessibility issues? Because sometimes if it's something that's expensive or difficult to get covered, or it requires an injection, all of these are important pieces. For somebody who's traveling a lot, this might be more difficult. For somebody that is afraid of needles, this could be a problem. So we have to weigh all of these things, and I always tell my patients and families, "It's not binding forever. If something doesn't workout, we could stop and go back and try something else."

So I try not to put too much weight on it because, otherwise, I think people feel overwhelmed. It's like "am I signing my life away? Is this the one big decision I have to make and everything falls from here?" Absolutely not. You know, this is one of the options and we have other ones. And if this doesn't work out, we certainly can try some other things.

One of the nicest things about, when we think about our biologic agents in general, so dupilumab is what we're talking about in this study, but there area lot of things that we need to keep it there. of course, is tralokinumab (Adbry), which is very similar in many ways, and one that's in development called lebrikizumab.

And I do think of these biologics, at least the ones we have so far, as being fairly comparable both in terms of safety and to some degree even efficacy. The good thing there, I think, is that because these are fairly targeted agents, the safety is actually quite, I think, quite reassuring and quite positive overall. Especially when we compare to the historic things that we had to use off label, none of those were labeled, but we use things like cyclosporine. We use things like methotrexate, a lot of powerful systemic immunosuppressive agents, and there we actually have quite a big number of things we have to talk about because they're more broadly immunosuppressive. Even prednisone or prednisolone, many people will recommend those things in many of my patients. I would even argue most of my patients with more moderate and severe disease, and that's really who we're talking about for the study, they've been on one or more courses of prednisone, and that's actually a pretty intense safety profile. When you think about it, we're used to it. So I think we're inured to the fact that we give it out a lot, but there are many safety issues.

So with dupilumab in particular, the conjunctivitis is something we're keeping an eye out for. We're literally keeping an eye on the eye. We also know that some people can have injection site reactions, so swelling, tenderness. We also have to keep in mind that some people could be allergic to it. It's quite rare, less than 1% in the trials, but it's something that can happen. And then more recently, only there's been these discursions of arthritis and arthralgia, some joint issues that we want to keep an eye out for. There are other things too, but they tend to be much lower on the list. So those are the ones thatI'm kind of keeping in mind and I make sure are top-of-mind during our discussion.

Transcript edited for clarity

Reference

1. Andrus E. FDA updates dupilumab label with hand, foot atopic dermatitis involvement. Dermatology Times. January 16, 2024. Accessed March 18, 2024. https://www.dermatologytimes.com/view/fda-updates-dupilumab-label-with-hand-foot-atopic-dermatitis-involvement

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