The Landscape of New Treatments for Eczema

MedPage Today brought together three expert leaders for a virtual roundtable discussion on atopic dermatitis: Moderator Peter A. Lio, MD, of Northwestern University Feinberg School of Medicine in Chicago, is joined by Linda F. Stein Gold, MD, of the Henry Ford Health System in Detroit, and Alexandra Golant, MD, of the Icahn School of Medicine at Mount Sinai in New York City.

This first of four exclusive episodes discusses the landscape of new treatments in atopic dermatitis.

Following is a transcript of the discussion:

Lio: Hello and welcome to today’s roundtable. I’m Dr. Peter Lio, I’m a clinical assistant professor of dermatology and pediatrics at Northwestern University Feinberg School of Medicine in Chicago, Illinois. And I’m delighted to be here with two amazing colleagues. I’d like each of them to introduce themselves. First, Dr. Stein Gold.

Stein Gold: Well, thanks so much for having me. My name is Linda Stein Gold and I’m a medical dermatologist. I run the clinical trials at Henry Ford Health and am thrilled to be here.

Golant: I’m Alexandra Golant. I’m on faculty at the Mount Sinai School of Medicine in New York. I am also a medical dermatologist with a focus on inflammatory skin diseases.

Lio: Thank you so much, both of you, for being here. I’d like to jump right in. And the first point, and I think really this is maybe a larger topic than we can cover in a short time, but really just hitting the highlights, the landscape of therapies, the new treatments in atopic dermatitis. It really has changed just in the last couple of years.

Maybe Dr. Golant, you could start us off. Could you tell us about some of the new systemic treatments that are now in our armamentarium?

Golant: Sure. To your point, I think there’s been an absolute explosion and it’s often felt like a rapid catch-up to diseases for which we had multiple treatments many, many decades ago. We’ve kind of seen in warp speed, atopic dermatitis catching up.

Just 6 and a half, almost 7 years ago, of course, dupilumab [Dupixent] was approved. And since that initial approval as our first FDA-approved systemic, tralokinumab [Adbry] followed several years later, followed by both our JAK [Janus kinase] inhibitors, abrocitinib [Cibinqo] and upadacitinib [Rinvoq]. So those are probably the newer kids on the block.

I hoped to have shared that lebrikizumab was also approved just a couple of weeks ago, but that unfortunately was delayed, but will be our next one in line, I think. And soon behind it, maybe in front of it now, nemolizumab also is very exciting as well.

So really changing the way, not only how we treat atopic dermatitis on a systemic level, but I think the way that we think about that moderate-to-severe patient and how we approach the treatment of a patient like that.

Lio: I love it. And of course that’s a huge part of the story for the more severe patients, but even for those patients, and particularly for those who are maybe more mild-to-moderate, we have the topicals. Dr. Stein Gold, could you tell us about some of the topicals in the last few years and maybe the ones that are just beyond the horizon?

Stein Gold: Absolutely, and it’s an exciting time for topical therapy. We know we need the systemic agents, but we also need the topical agents. We’ve had ruxolitinib [Opzelura], which was FDA approved for mild-to-moderate atopic dermatitis, and that’s a topical JAK inhibitor, targeting both JAK1 and JAK2. And we have approval down to age 12. So that’s great because it’s a nonsteroidal option. You can use it anywhere on the body. And what we really love about these new non-steroidals is that the local tolerability is really exceptional, not a lot of stinging and burning.

And as you mentioned, just on the horizon, we have some other non-steroidal options. We have tapinarof [Vtama], which is an oral hydrocarbon receptor agonist that has completed phase III clinical trials all the way down to age 2. And we have roflumilast [Zoryve], which is a topical phosphodiesterase type 4 inhibitor, also being studied in children as well as adults. So the landscape has changed, and I think it’s a really exciting time.

Lio: Amazing. And I think every patient benefits when we have more options because, of course, we meet patients all the time that don’t have a treatment that works for them yet. So we’re literally waiting for new things. But even for those that have stuff that may be helping, we can always ask the questions, can we do better, can we alter it, do we need to change, or if something stops working.

One of the most exciting things for me too is this ability that I think we’ve seen this new movement towards, the “treat to target,” that has also been elevated. Would you guys agree that what we used to settle for even just 5 or 6 years ago, getting people pretty better or a little bit better, now we’re starting to say no, the new gold standard is to get you much better, if not clear or almost clear all of the time.

Stein Gold: I agree with you, Peter. I mean, we’ve seen this in psoriasis. Many years ago we thought getting patients with psoriasis clear was a pipe dream, and now we know we can get the majority of our psoriasis patients clear, almost clear. We’re not quite at the same level with atopic dermatitis, but we’re so much better than we used to be. And I agree, aim for clear skin.

Golant: I think too, what’s interesting looking at the data for both the topicals and the systemics coming, is being able to look at those deeper endpoints. Not just an EASI-75 [Eczema Area and Severity Index reduction of ≥75% from baseline], but getting patients to an EASI 90, or 90% clear, not just a four-point improvement in itch, but getting patients actually truly to an itch-free state. So you see it trickle down, and that gold standard continues to evolve.

And I always say with more options. I always say to my patients with atopic dermatitis, it’s a good time, it’s an exciting time, to have AD [atopic dermatitis] because we finally have things we can experiment with, things we can play with, and options that we can provide for you.

Lio: I couldn’t agree more, and I love that you brought up itch because the other piece of the puzzle, of course, is obviously we want to get patients clear or almost clear from an objective skin standpoint, but there’s so much more to it than just the way the skin looks on that day. And itch is one of them; sleep is another — these patient-reported outcomes are huge.

And I’ll take this last minute to put in my plug for what I think is the most powerful new tool that I’ve ever seen. It’s the ADCT, Atopic Dermatitis Control Tool. Six questions, non-branded, patients can do it themselves. Clinicians, when I do telemedicine, I literally read it to the patient. I’m like, let’s do it together. We just do it together online. And it is so powerful because it captures a lot of these pieces and it has been validated.

So I love that we’re really moving everything forward. And I think the treatments, these new treatments in particular, have paved the way.