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Patient Case #2: Adolescent Male With AD


Jonathan I Silverberg, MD, PhD, MPH; Elizabeth Swanson, MD; Brad Glick, DO, MPH, FAOCD; and Andrew Blauvelt, MD, MBA, discuss their initial impressions of an adolescent patient with AD, focusing on systemic therapy.

Jonathan I Silverberg, MD, PhD, MPH: We’ve got an adolescent with atopic dermatitis [AD] since early childhood. He loves to play sports that require long hours of training in the sun. We mentioned earlier about the soccer player. Atopic dermatitis affects multiple areas on the body that are worsened by heat and sweat. He has AD lesions on the face most of the time. The patient has been on long-term topical steroids, which are becoming less effective, and is now experiencing skin atrophy from all the steroid use. He’s worried about long-term steroid use and doesn’t want to use topical steroids going forward, something we’ve already heard. He’s already expressed the desire to be more independent in his treatment regime and finds applying lotions and creams to be burdensome. Now, this is a classic scenario. Where do we go from here? What’s your impression?

Elizabeth Swanson, MD: The only topical option I would present to this patient would be topical ruxolitinib and explain that it’s a nonsteroid with efficacy that is profound. It’s a nice cream, not a goopy ointment. It doesn’t sting or burn, so it might be a topical he could wrap his head around, probably the only topical he could potentially wrap his head around. I’m assuming by adolescent, this child is older than 12, and so I think this person definitely needs a systemic therapy option, either dupilumab, abrocitinib, or upadacitinib.

Jonathan I Silverberg, MD, PhD, MPH: What do you think?

Brad Glick, DO, MPH, FAOCD: I’m screaming along with you. To me, we don’t even say moderate to severe, this is a severe impairment of activities of daily living. I look at this adolescent and I’m just thinking systemic therapy. I need to get this child better, and I need to get him better quickly. I love sports. This is someone trying to play sports. That’s a significant impairment of his life. I’m jumping in with systemic therapy right away.

Jonathan I Silverberg, MD, PhD, MPH: It’s such an important issue. I’ve had patients who were counseled by other dermatologists to stop playing sports as a coping mechanism to avoid flaring the eczema. I tell the parents, I will not stop the sports because this is what he enjoys, and it’s going to be so good for his overall health. But my job is figuring out how to get him clear enough to be able to play those sports and not flare up because it’s such a big issue.

Brad Glick, DO, MPH, FAOCD: What we know now with the therapies we have, and I’ll use dupilumab as an example, we’re not just treating inflammation, but we’re also improving the skin barrier. You add in the emollients we’re using for these patients, and to Dr. Blauvelt’s point, this is a classic opportunity here to use barrier restoration and monotherapy with a biologic therapy.

Jonathan I Silverberg, MD, PhD, MPH: I agree. So, we talked about dupilumab. What do we think about for this type of patient in terms of tralokinumab as an option as well? Could we use that as a first line here?

Elizabeth Swanson, MD: I think technically it is still for ages 18 and up. I think it’s going to be 12 and up soon. But that would be something that would potentially be in the way. It’s going to take me a bit to choose tralokinumab first over dupilumab. I don’t think I’ve seen anything that tells me I should. Tralokinumab is 2 shots each dose instead of 1. I am a believer that tralokinumab can work in a dupilumab failure, but I’m not sure that I’ve seen any evidence that I should choose tralokinumab first. I don’t know if other people feel differently, but at least right now, in March 2023, if I’m choosing a biologic, I’m choosing dupilumab.

Jonathan I Silverberg, MD, PhD, MPH: Interesting, thoughts?

Brad Glick, DO, MPH, FAOCD: I couldn’t agree more, and if we go with reasonable guidelines and indications for therapies, we’d be starting with dupilumab. I think after a few months, or in the world of Jonathan Silverberg, after 4 weeks or a couple of injections, we could clearly have a discussion given the approval of both oral systemic Janus kinase inhibitors down to the age of 12 now. We don’t know this adolescent’s age, but we assume it’s 12 or higher; that would be a role for these 2 wonderful Janus kinase inhibitors now in our toolbox.

Elizabeth Swanson, MD: Which also segues to a related question, how would you choose between upadacitinib and abrocitinib now? They’re both approved for ages 12 and up. I don’t know if anybody has any thoughts or is willing to share.

Jonathan I Silverberg, MD, PhD, MPH: I’m going to give the tough one to Andy, dupilumab versus tralokinumab, you know the trial data as well as anyone. Also, abrocitinib versus upadacitinib, where do you put this?

Andrew Blauvelt, MD, MBA: I think this is a patient who’s an ideal candidate for all 4 drugs, I really do, and including tralokinumab first. The reason I say that is a slight hunch, and feeling, and gut that there’s less conjunctivitis with tralokinumab than there is with dupilumab. There’s a hint of that in clinical trial data, but it’s my experience. I have not seen much conjunctivitis or it’s been mild with both the selective IL-13 [interleukin-13] blockers of tralokinumab, and the up and coming one, lebrikizumab. If patients have bad facial eczema, it’s a risk factor for dupilumab-associated conjunctivitis or ocular surface disease. It gives me a bit of pause when I see a patient with bad facial disease or history of allergic conjunctivitis, which a lot of these patients have. I probably would choose tralokinumab with that type of presentation versus dupilumab. Again, that’s a bit more the art of medicine. There’s not a lot of hard science behind that, but it’s just from my experience of using both drugs.

Jonathan I Silverberg, MD, PhD, MPH: With tralokinumab there’s also the on-label ability to go to a lower maintenance dose, which for a lot of patients, especially the children, but everyone really, it’s half as many shots, so it’s something that’s attractive to them.

Andrew Blauvelt, MD, MBA: The other hard choice if you decide the JAK inhibitor route, which I think is a great choice as well, again, this is more theoretical, but upadacitinib has slightly better efficacy results than abrocitinib. If you look at the in-vitro selectivity, you see upadacitinib with a bit of JAK2 activity; it’s described as a predominantly JAK1 blocker. And then if you look at abrocitinib, it’s a selective JAK1 blocker. Is that the reason we see a little less efficacy with that, does a bit better selectivity for JAK1 lead to fewer adverse effects because it’s not blocking JAK2 at all? It’s in the theoretical realm here. We need data, we need data to back up what I just said. I think there’s a possibility that abrocitinib may be safer than upadacitinib. Again, it’s going to take time and data.

Transcript edited for clarity

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