VIDEO: Biologics, JAK inhibitors and other new options in atopic dermatitis

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Over the last few years, we've seen an unprecedented increase in interest in helping us to manage atopic dermatitis from industry. And that means that we have topical and systemic agents that are either in the pipeline or have been in trials and now are even on the market that we can actually use for our patients. So yes, there are many products that I'm excited about. I was just thrilled when the FDA a few years back approved for the first time dupilumab (Dupixent; Sanofi Genzyme/Regeneron) for adolescents and then 6- to 11-year-olds. And now we're delighted to have the option for those under 6 to be able to use dupilumab, the first biologic available. Now that's changing too. We have tralokinumab (Adbry, LEO Pharma) now available for adults. In Europe, it's available for children as well. Here in the United States, that hasn't happened quite yet, but we're anticipating it soon.

We also have lebrikizumab (Almirall, Lilly) coming out in the near future as another biologic. Lebrikizumab and tralokinumab both target the cytokine interleukin-13, although by different mechanisms. So it may be that all three of these biologics that will be out soon are going to give us many options. And just because one doesn't work or one stops working, just like in the world of psoriasis, will allow us not to have to worry about having to go back to immunosuppressants, but rather to use an alternative one if there is a problem with the first one. We also have now available [Janus kinase (JAK)] inhibitors. This gives the alternative of an oral agent that can be used and more easily stopped and started perhaps. But it also brings with it some baggage. Of course, the JAK inhibitors have a boxed warning attached to them, and in contrast to the biologics, do require laboratory monitoring. I don't know that we're going to have to worry so much in dermatology about the kind of risks that are occurring in adults over the age of 50 who have at least one cardiovascular risk factor, have rheumatoid arthritis, which is a chronic disease that has a lot of associations, and then on top of that are taking tofacitinib (Xeljanz, Pfizer), which is not as focused as the more selective JAK1 or JAK1/2 inhibitors.

So, I think that we're all concerned, in particularly in children, about knowing the real risk when we're dealing with the healthier population of having atopic dermatitis and a younger population, etc, but of course that remains to be seen and it might be years before we really know the true safety of these agents. But of course, we're hoping that they prove to be very safe because it's in many ways easier to take a daily pill than to give yourself a shot, especially when parents and children are struggling about that intervention despite its wonderful impact on the disease and quality of life. So, we have upadacitinib (Rinvoq, AbbVie) and we have abrocitinib (Cibinqo, Pfizer) on the market now for adolescents 12 and above and adults, and that's added another exciting opportunity for choice when we're making joint decision-making with families, with patients, that we have many options. Now there are others coming out. We're going to see more JAK inhibitors. We're going to see more biologics, I'm sure, in the future and maybe even some orals coming out that are going to be more targeted, but probably not this year. We also have topicals, and it's great to have these as well.

We're now beyond the 20th anniversary, believe it or not, of the topical calcineurin inhibitors. So tacrolimus, pimecrolimus, have been around now for more than 2 decades, and it's very clear from numerous long-term studies that these potential risks early on that were conceived of — that there would be an increased risk of any kind of cancer, particularly the lymphoma or non-melanoma skin cancer — have just not been realized. They have a clean bill of health, and I wish that the box warning would come off of them. But we certainly use them freely and with great comfort now having these 2 decades of experience under our belt.

Crisaborole (Eucrisa, Pfizer) has come out more recently and is a [phosphodiesterase-4 (PDE4)] inhibitor that entered the armamentarium as a nonsteroidal that could be conceived of for those who are concerned about steroids and certainly for maintaining good control that one gains from a topical steroid. We also have topical ruxolitinib (Opzelura, Incyte) now that's most recently come out as a topical JAK inhibitor that is available for those 12 years of age and above, not yet for younger children although studies have been performed. And that gives another option that I hope is going to step into that niche of being an effective topical that doesn't sting or burn in contrast to what can happen with topical calcineurin inhibitors and also crisaborole.

We also have now on the market two topicals for psoriasis that are also in trials now for atopic dermatitis. One is a different phosphodiesterase-4 inhibitor called roflumilast (Zoryve, Arcutis). And the other is the first of the aerial hydrocarbon agonists that is also in the market called tapinarof (Vtama, Dermavant Sciences) for psoriasis. So, these two are in trials now, and I suspect they're both going to come out for atopic dermatitis in the near future. So, we'll have a variety of new nonsteroidals available for our patients, and I see them particularly helpful for key areas that may be more sensitive skin, like the face, and also for using as part of a maintenance regimen. It's always easier to get patients under control by hitting them hard with something like a topical steroid which is great for a few weeks. But for maintenance, we want to have a regimen that allows us to dial down to something that's either not a steroid or is only intermittently used.

So, I'm delighted about all of these options. I will certainly be using them in my patients, and when they come on the market, or with the ones newly on the market, we'll start getting more experience and have a better idea of how to best juggle our wealth now of topical and systemic agents.