Atopic Dermatitis: Pathophysiology Driving Management Decisions - Episode 12

Evolving Treatment Landscape of Atopic Dermatitis

Emma Guttman, MD, PhD, leads a discussion revolving around other drugs in development and the future for treatments in atopic dermatitis

Peter A. Lio, MD: What about agents in development? We finally have the tip of the spear: dupilumab is the first big new systemic agent, but there are many in development. Emma, could you walk us through the crazy world of things in development?

Emma Guttman, MD, PhD: Yes. It’s an exciting time for atopic dermatitis. Dupilumab opened the door for all of this development that we have. We have oral medications, we have JAK [Janus kinase] inhibitors, and there always will be patients who will prefer an oral agent. They would not like an injectable, and orals also offer some flexibility for patients, particularly patients who have more moderate disease. They will not use a medication all the time. There are also patients for whom it is hard to come to terms with the fact that they have a chronic disease, so they like the idea of starting and restarting at any time.

We also have things on the other hand. In terms of oral agents, we have the JAK inhibitors primarily, and then we have other biologics, such as IL-13 antagonists. We have 2 in development and 1 finished with phase 3, so I think we’ll have a new drug in 2021. These are exciting as well. They are specific only to IL-13, and they both have good safety as well as good efficacy: tralokinumab and lebrikizumab.

We then have other medications that are a bit earlier in the game, but they are also exciting, such as the OX40 antagonists, the OX40 ligand antagonists, and the IL-1 and IL-36 antagonists. It’s an interesting and exciting time for the field.

Peter A. Lio, MD: Linda, I know that you too are involved in lots of clinical trials. Are there some that you’re looking forward to exploring and hearing more about?

Linda Stein Gold, MD: I agree with Emma. There is an explosion of new possibilities for atopic dermatitis. I’m excited about the new biologic agents. We also have an IL-31 agent, which is targeting the itch, and that is in phase 3 right now. Let’s not forget about some of the topical agents too. We have new topical JAK inhibitors that look great. Tapinarof is an oral hydrocarbon reductase agonist, which is also exciting.

We’re putting more time, money, and effort into atopic dermatitis than almost anything else right now. It’s a disease that warrants new treatment. The landscape over the next 5 years is going to look different. I agree with Emma: there is a place for a lot of these drugs. With the oral JAK inhibitors, you want to stop and start because you may not need a systemic agent all the time. We don’t have to worry about the potential for antibody development with an oral JAK inhibitor, so we can potentially stop and start, whereas with the biologic, we may not want to do that.

With the topical agents, especially when the patient has disease on the face and around the eyelids, we need nonsteroidal drugs, and we’re going to have a lot of new options in the coming years, so it’s exciting.

Peter A. Lio, MD: It is. I’ve been interested in this question for the last couple of years about the shape of someone’s atopic dermatitis. By that I mean to ask about what’s happening throughout the year. Is it bad all the time with just small fluctuations? Are they the people who get 1 big spike in the winter or spiky disease? So trying to think about this, and we can identify these trends and patient preferences because it has to be a shared decision-making piece. There are many unmet needs, so I totally agree. With these new potential products, hopefully we’ll get all of them or at least some of them to make it through the gauntlet of the FDA approval process.

We would like to have new topical agents that will hopefully be safer than topical corticosteroids, especially for the medium-term and long-term use. They may be just as powerful, and maybe the patient will be able to get control in situations where we haven’t been able to treat topically before. We would like to have oral agents that we can start and stop easily that work fast: prednisone-like speed would be incredible.

There may be new biologic options that might be better suited for patients for a number of reasons. We’re now slowly collecting patients who either didn’t succeed with dupilumab or had adverse events. Those are patients who may be up for another biologic, so that would be an incredible addition. At the same time, we selfishly win on the back end of all this because not only do we get these new treatments, but we learn more about the disease as well.

With the fact that all this attention is spent on atopic dermatitis—its ramifications, its quality of life, and all the educational endeavors that are going forward—everybody wins. The patients win because people stop dismissing it and pooh-poohing it. We win because we are able to connect with those patients and hopefully get them better as quickly as possible. It’s one of those things where all ships start to rise.

We lived through the decade-plus of psoriasis, and it was exciting. I was like a little puppy dog looking at it through the window. I was not a psoriasis expert. I take care of lots of patients with psoriasis, but that’s not my main expertise. I feel lucky that we are now entering the phase of atopic dermatitis. We’re quite in it, and there is going to be a flurry of new treatments, new ideas, and new understanding, so I’m excited that we’re right the cockpit for all this happening.

On that note, I’ll wrap up. I appreciate this. It’s been a wonderful discussion, and we hope that you all found this information to be valuable to your clinical practice. Thank you all for watching this Dermatology Times® Viewpoints program.