PeerView - Bridging the Gap to Increased Patient Satisfaction in Moderate to Severe Atopic Dermatitis: Understanding the Role and Clinical Utility of Targeted Therapy

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Question 1/5

Which of the following cytokines is a driver of chronic type 2 inflammation in AD, binds directly to sensory nerves, increases sensation of itch, and is inhibited by lebrikizumab?

• IL-13

Explanation: AD is a chronic, pruritic, immune-mediated inflammatory dermatosis characterized by a Th2 immune response phenotype and can be associated with systemic inflammation (Napolitano M et al. Front Med [Lausanne]. 2023;10:1165098). IL-4 and IL-13 are the main drivers of the Th2 inflammatory pathway, and, along with IL-31, are pruritogens (Bernardo D et al. Am J Clin Dermatol. 2023;24:753-764). Lebrikizumab is a fully humanized IgG4 antibody that acts by binding IL-13 on a nonreceptor-binding domain, where it thus blocks heterodimerization of IL-13Rɑ1 with IL-4Rɑ, preventing downstream IL-13 signaling. Lebrikizumab does not prevent IL-13 from binding to the IL-13Rɑ2 "decoy" receptor that plays a role in regulating IL-13 through internalization (Napolitano M et al. Front Med [Lausanne]. 2023;10:1165098; Bernardo D et al. Am J Clin Dermatol. 2023;24:753-764; Dupixent [dupilumab] Prescribing Information. https://www.accessdata.fda.gov/drugsatfda_docs/label/2023/761055s050lbl.pdf).

Question 2/5

Your patient is a 19-year-old Black man who claims the topical corticosteroids he has been using for AD are not working. He complains that at least once per month, persistent itching keeps him up almost all night, causing him to scratch to the point of bleeding. Upon examination, you observe rashes that appear violet in color, significant lichenification, oozing lesions, some patches of dyspigmentation, and signs of a secondary bacterial infection from scratching on his torso, arms, and legs. How would you categorize the severity of his AD?

• Moderate to severe

Explanation: Although objective and subjective measures of AD severity exist (ie, SCORAD, pruritus NRS), they are not always used in clinical practice. Although the use of objective and subjective tools is encouraged, the clinician should assess the extent and severity of the lesions, the symptom severity, the disease course, and the quality-of-life impact of the disease. Because this patient's initial therapy was ineffective, the itching has impacted his sleep, and he has signs of inflammation, he likely has moderate to severe AD with frequent flares (Gooderham MJ et al. J Cutan Med Surg. 2018;22[suppl 1]:10S-16S; Suh TP et al. J Am Acad Dermatol. 2020;82:1187-1194; Simpson E et al. J Am Acad Dermatol. 2020;83:839-846).

Question 3/5

Consider the above 19-year-old male patient. What therapies would you consider?

• Suggest a switch to a topical calcineurin inhibitor and add a biologic therapy

Explanation: The patient has frequent flares and persistent symptoms despite an adequate trial of topical corticosteroids, so therapy should be escalated. Adding crisaborole or using stronger topical corticosteroids would be more appropriate for patients with mild to moderate AD. Oral corticosteroids are not an optimal choice as they should not be used long term. A topical calcineurin inhibitor may be appropriate as some dyspigmentation has been noted, which can occur with long-term use of topical corticosteroids, along with a biologic agent such as dupilumab or tralokinumab to help minimize flares and attain long-term disease control (Simpson EL et al. J Am Acad Dermatol. 2017;77:623-633; Boguniewicz M et al. Ann Allergy Asthma Immunol. 2018;120:10-22; Wollenberg A et al. J Eur Acad Dermatol Venereol. 2020;34:2717-2744).

Question 4/5

Which of the following statements is true regarding the use of topical therapies, with or without systemic therapy, for AD?

• A substantial number of adult and adolescent patients, and their physicians, report dissatisfaction with topical AD therapies, with or without systemic therapy

Explanation: Results of a recent study examining treatment satisfaction/dissatisfaction among adult and adolescent patients with AD who used topical therapies with or without systemic therapy found that a substantial number of patients and physicians alike reported dissatisfaction with the treatment (Anderson P et al. Dermatol Ther. 2021;11:1571-1585).

Question 5/5

You are evaluating a patient with moderate to severe AD who has not experienced relief after months on topical therapies and wants to know what they can do next. Your patient has also expressed a desire to not have to remember to take pills on a daily basis or to have to come to your office frequently. What would your next step be?

• Suggest they try a biologic therapy such as dupilumab or tralokinumab (or lebrikizumab, if approved)

Explanation: Stepping up therapy after the use of topical therapies alone for moderate to severe AD can include the use of phototherapy, which typically requires a few visits per week; a biologic agent such as dupilumab or tralokinumab which are given by injection usually every 2-4 weeks; or a JAK inhibitor such as abrocitinib or upadacitinib which are oral medications taken every day. Increasing the dose of topical therapy and not making any change in treatment otherwise would not be the best step (Boguniewicz M et al. Ann Allergy Asthma Immunol. 2018;120:10-22).

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Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica

Clinica Victoria en San Pedro: 4000-1054
Momentum Escazu: 2101-9574

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