Novel Systemic Agents for Atopic Dermatitis
Atopic dermatitis, more commonly known as eczema, is a chronic skin condition that can significantly diminish one’s quality of life, primarily due to the debilitating itch it produces. Fortunately, in recent years, new therapies have emerged that hold great potential for effectively managing eczema. This article will explore a diverse range of medical treatments for eczema, focusing on the latest systemic treatments.
What Treatments Are Usually Tried First?
First-line treatments for eczema include topical anti-inflammatory agents (eg, topical corticosteroids and topical calcineurin inhibitors). Phototherapy, commonly referred to as light therapy, is often considered for those who have not responded to topical agents. Light therapy can be demanding, though, as it often requires multiple doctor’s office visits every week, which can be inconvenient for many people. Additionally, prolonged exposure to specific light therapies has been associated with an increased risk of skin cancers, which restricts its use as a long-term maintenance therapy for eczema.
What Is a Systemic Agent, and When Are They Used for Eczema?
Systemic agents are a class of medical treatments that work systemwide in the body and are typically given orally or as a subcutaneous injection (an injection under the skin) in the dermatologic setting. They are typically recommended when eczema persists despite the use of topical treatments and/or phototherapy, or when the condition significantly affects an individual’s daily activities and overall well-being, particularly when persistent itching interferes with sleep. A diverse array of systemic agents are available for treating eczema, ranging from short-term remedies that provide relief for acute flares (eg, oral steroids, cyclosporine) to long-term maintenance therapies.
How Do Newer Systemic Agents Work?
Recent advances in medical treatments for eczema have introduced promising systemic agents such as dupilumab (Dupixent), tralokinumab (Adbry), and abrocitinib (Cibinqo). These medications are specifically designed to target the primary culprits in the inflammatory response responsible for eczema.
Dupilumab (Dupixent) is a biologic that helps block the source of inflammation in eczema. It is administered via a subcutaneous injection using a pen or syringe every other week. It is currently US Food and Drug Administration (FDA) approved for eczema that is inadequately controlled by topical treatments in adults and children ages 6 months or older. It is also FDA approved for asthma, which is commonly found in association with eczema.
How Did the FDA Decide to Approve Dupilumab?
More than 1379 patients were studied in 2 major clinical trials, where dupilumab was tested against a placebo. The clinical studies looked at how many physicians rated patient improvements as “clear” or “almost clear.” Of patients receiving dupilumab, 36%-38% achieved a rating of “clear” or “almost clear,” compared with only 8% of patients receiving a placebo. About half of patients with eczema improved at least 75% on the medication, compared with only 12%-15% on the placebo. The medication improved itching, depression, and overall quality of life for patients. The clinical trials were convincing that dupilumab works, and it works well.
What Risks Are Associated with Dupilumab?
With all new medications, there is less data available, which is something to keep in mind. Sometimes serious side effects or adverse events are only apparent years after a drug enters the market. There are unknowns until physicians get more information about associated medical problems.
From the clinical trials, it is known that dupilumab increased eye problems. Specifically, patients on dupilumab should be aware that there is an increased risk for conjunctivitis (also known as pink eye) and keratitis, which is corneal inflammation that presents as eye redness and irritation.
What About Tralokinumab and Abrocitinib?
Tralokinumab (Adbry) is another biologic that helps block the source of inflammation in eczema. It is administered via a subcutaneous injection using a syringe every other week. After several months of treatment, the frequency of administration of the medication may decrease based on an individual’s response. Tralokinumab is currently FDA approved for eczema that is inadequately controlled by topical treatments in adults who are 18 years or older. As with dupilumab, conjunctivitis and keratitis are among the potential side effects associated with this medication.
Abrocitinib (Cibinqo) is an oral medication that blocks the transmission of inflammation in eczema. It is FDA approved for eczema not adequately controlled with another systemic medication in adults and children 12 years or older. However, like other JAK inhibitors, abrocitinib carries a black box warning due to the increased risk of serious infections, malignancies, and major cardiovascular events such as myocardial infarction and stroke.
How Do You Decide Which Systemic Agent to Use?
When considering a systemic treatment for eczema, several factors come into play, including the individual’s age and medical history, the method and frequency of administration, and the physician’s prescribing practices. While there are many novel therapies available, dupilumab is the most widely studied and prescribed by dermatologists, and it is currently the only one approved for use in young children. Tralokinumab is a newer medication and is still being studied, which has limited its everyday use in dermatology. The potential association between abrocitinib and cardiovascular events is an active subject of research, and it may limit the medication’s use in patients with preexisting cardiovascular risk factors, such as coronary artery disease, hypertension, and diabetes.
Conclusion
Systemic agents play a crucial role in the management of eczema, and ongoing research continues to advance the field in dermatology. If you have eczema, it is important to consult with a dermatologist to explore which treatment options may be best for you.
References
Bieber T, Simpson EL, Silverberg JI, et al; JADE COMPARE Investigators. Abrocitinib versus placebo or dupilumab for atopic dermatitis. N Engl J Med. 2021 03 25;384(12):1101-1112. PubMedId: 33761207.
Paller AS, Siegfried EC, Cork MJ, et al. Laboratory safety from a randomized 16-week phase III study of dupilumab in children aged 6 months to 5 years with moderate-to-severe atopic dermatitis. Paediatr Drugs. 2023 Jan;25(1):67-77. PubMedId: 36529811.
Reich K, Thyssen JP, Blauvelt A, et al. Efficacy and safety of abrocitinib versus dupilumab in adults with moderate-to-severe atopic dermatitis: A randomised, double-blind, multicentre phase 3 trial. Lancet. 2022 Jul 23;400(10348):273-282. PubMedId: 35871814.
Simpson EL, Merola JF, Silverberg JI, et al. Safety of tralokinumab in adult patients with moderate-to-severe atopic dermatitis: Pooled analysis of five randomized, double-blind, placebo-controlled phase II and phase III trials. Br J Dermatol. 2022 Dec;187(6):888-899. PubMedId: 36082590.
Wollenberg A, Blauvelt A, Guttman-Yassky E, et al; ECZTRA 1 and ECZTRA 2 study investigators. Tralokinumab for moderate-to-severe atopic dermatitis: Results from two 52-week, randomized, double-blind, multicentre, placebo-controlled phase III trials (ECZTRA 1 and ECZTRA 2). Br J Dermatol. 2021 03;184(3):437-449. PubMedId: 33000465.
Last modified on September 25th, 2023 at 2:27 pm
