New developments in atopic dermatitis (2023)

teaser

Christopher B Yelverton
MD MBA

Steven R Feldman
MD PhD

Alan B Fleischer, Jr
MD
Department of Dermatology
Wake Forest University School of Medicine
Winston-Salem, NC
USA
E:[emailprotected]

(Video) New Developments in the Treatment of Atopic Dermatitis

Atopic dermatitis (AD), also known as atopic eczema, is a common disorder characterised by intense pruritus (itching), xerosis (dryness) and lichenification (thickening) of the skin. The condition generally begins in the first year of life with a patchy rash in flexural areas and often progresses to other areas of the body. Epidemiological studies have indicated that AD affects 12–18% of children. Incidence is highest in industrialised nations for reasons that are unclear. Although AD may resolve spontaneously, often near puberty, adult AD is increasing in prevalence.

Clinical features
Patients with AD often have a family or personal history of atopic diseases, such as asthma and seasonal allergies, in addition to AD. This points to a heritable nature for AD, although the exact genetic contribution is still being studied. The diagnosis of AD is clinical, and laboratory workup is typically not necessary. In some cases a scraping is obtained to rule out fungal infection, and skin biopsy may be performed to confirm an unusual case. Histologically, the hallmark of AD is spongiosis (oedema) in the stratum corneum, which is most prominent in the acute phase of the disease. Later, the condition progresses to show acanthosis and lymphocytic infiltrate.(1) Patients may show increased eosinophils in tissue and/or blood. Serum immunoglobulin E (IgE) levels are elevated in a majority of atopic patients, but this finding is not pathognomonic for AD.(2,3)

Pathophysiology
There are a number of theories regarding the development of AD. A complex interplay of genetic, environmental and physical factors is most likely responsible for the condition.(4) The primary event is thought to involve the immune activity of T-helper-2 (Th2) cells, resulting in an overproduction of cytokines (interleukin-4 [IL-4] and others) and IgE that predispose to atopy.(5) Eventually, Th1 activity is also suppressed. Environmental triggers such as dust mite antigens in the home appear to be important modulators of the immune response and may play a role in the development of AD.(6) Studies have shown that patients with AD are frequently colonised with Staphylococcus aureus, but the exact significance of this colonisation is unclear.(7,8) Additionally, individuals with AD are thought to have abnormalities in the stratum corneum, leading to increased water loss and xerosis. The “itch–scratch–itch” cycle of the disease perpetuates the problem, due to further mechanical disruption of the epithelial barrier.(1)

Treatment
A variety of topical and systemic treatments are available for AD. The goals of treatment are to restore moisture, control itch and modulate the inflammatory response. Several excellent reviews have examined the published evidence supporting various AD therapies.(6,8,9)

(Video) Exciting Advances in the Treatment of Atopic Dermatitis

Topical corticosteroids
Topical corticosteroids have traditionally been the first-line treatment for AD. Topical steroids are classified according to strength and come in a myriad of vehicles, such as creams, ointments, lotions, solutions, shampoos and foams. A discussion of all of the formulations of topical steroids is beyond the scope of this review. The choice of a topical steroid preparation is typically based on location and severity of lesions, age of the patient and tolerability. The advantages of steroids include relatively rapid onset of action, high efficacy and relatively low cost. Typical dosing regimens include either intermittent therapy with mid- to high-potency steroids or daily usage of milder steroids. Inpatients with severe AD are occasionally treated with occlusive wraps using steroids. Long-term use of topical corticosteroids may lead to tachyphylaxis (decreased efficacy due to tolerance), thinning of the skin, telangiectasias and, rarely, adrenal suppression. Skin atrophy, the most worrisome adverse event, was demonstrated at six weeks in several studies.(10)

Topical immune modulators
The most exciting advance in the treatment of AD and many other inflammatory skin conditions is certainly the development of topical immune modulators (TIMs). At present, there are two TIMs available for use in AD: tacrolimus and pimecrolimus. These agents are selective inhibitors of calcineurin, which inhibits the immune activity of Th2 cells and antigen-presenting cells in the skin (Langerhans cells).(11–13) Tacrolimus (Protopic; Fujisawa) is available as 0.03% and 0.1% ointments for the treatment of moderate-to-severe AD. Pimecrolimus (Elidel; Novartis) is available as a 1% cream for treatment of mild-to-moderate dermatoses. One large, unpublished head-to-head comparison has shown that tacrolimus is more effective than pimecrolimus with a similar adverse effect profile. Another smaller trial already published supports these differences in efficacy, but suggests there may be short-term tolerability differences.(14) The TIMs have several distinct advantages over topical steroids. First, they do not have any effect on collagen synthesis and, therefore, they have no potential for skin atrophy or striae formation. For this reason, they are thought to be safer for use on the face and intertriginous areas. Bioavailability studies of both topical tacrolimus and pimecrolimus have shown minimal systemic absorption in most patients.(6,12,13) These agents represent a significant advance in AD treatment, as they are steroid-sparing and specifically target the cells implicated in AD. Work is underway to develop new vehicle formulations of TIMs that may be more convenient for some patients.

Other topical therapies
Topical emollients are used to moisturise and protect skin in atopic patients, and should probably be used frequently. There is minimal published evidence regarding the efficacy of emollients in reducing the severity of AD, although they are thought to increase patient comfort.(6,8) Topical doxepin has been used to control itch, but data are limited.(8)

Systemic therapies
Systemic therapies for AD are generally reserved for the most severe and resistant cases, out of concern for the adverse effects of these medications. Ciclosporin is one of the most common systemic treatments used for recalcitrant AD. This medication has a mechanism of action similar to that of tacrolimus and pimecrolimus, in that it inhibits calcineurin. It can cause renal, hepatic and haematological dysfunction with prolonged used. Ciclosporin is typically used only for short-term bursts of treatment during severe flares.(6,8,15) Although they have not been studied extensively in AD, systemic corticosteroids are often used in acute flares to control symptoms until transition back to topical therapies is appropriate.(6,8) Systemic steroids have potent anti-inflammatory effects. Concern over long-term adverse effects and rebound flares after discontinuation are the limiting factors in the use of systemic steroids. Systemic antibiotics are sometimes used for superficial infection and skin colonisation, but no studies have shown significant efficacy for these treatments.(6,8) In the same way, oral antihistamines have shown little or no benefit in AD, as histamine is not known to play a prominent role in AD.(8)

(Video) New Developments in Allergic and Inflammatory Diseases

Many other systemic therapies have been used for AD, including methotrexate, interferon gamma, azathioprine, mycophenolate mofetil and intravenous immunoglobulin. Methotrexate, which is the most commonly used of these agents, has substantial anecdotal effectiveness in the absence of controlled trials.(6,8) Oral pimecrolimus, which is currently in phase II trials for AD and other immune- mediated skin conditions, has shown great promise. This medication will likely be similar to oral ciclosporin in terms of mechanism of action and adverse effect profile.(16)

Phototherapy
Ultraviolet (UV) light, which is an important mediator of the immune response in the skin, has shown some efficacy in the treatment of AD;(6) UVB or UVA may be used. Recurrence of disease is common following discontinuation of treatment. There is also some concern for increased cutaneous malignancy risk.

Allergen restriction
It is thought that environmental and dietary allergens may play a role in atopic diseases. In truly atopic individuals, particularly those who have undergone allergen testing, attempts to remove allergen triggers may be beneficial. However, the difficulty in effectively removing either environmental allergens (such as dust mites) or food triggers may prove too difficult to accomplish.(6,8) Skin irritants, such as detergents and perfumes, may also play a role.(6) Additional research is ongoing regarding these environmental risk factors.

(Video) Latest developments for new treatment strategies in atopic dermatitis

Implications for hospitals and pharmacies
AD is rarely severe enough to warrant inpatient treatment, but it may be necessary in a few patients who are refractory to attempts at outpatient management. Moreover, AD is common and can affect a significant proportion of patients admitted for other conditions. A key element of hospital preparedness is the availability of common treatment options. Additionally, availability of minimally irritating linens, soaps and moisturisers will go a long way to improve comfort.

References

  1. Semin Cutan Med Surg 2004;23:39-45.
  2. Allergy 2004;59:561-70.
  3. J Allergy Clin Immunol 2004;114:150-8.
  4. Allergy 2003;58:5-12.
  5. Clin Exp Allergy 2004;34:559-66.
  6. Health Technol Assess 2000;4:1-191.
  7. Acta Derm Venereol 2004;84:32-6.
  8. J Am Acad Dermatol 2004;50:391-404.
  9. Br J Dermatol 2004;151 Suppl 70:3-27.
  10. BMJ 1999;318:1600-4.
  11. J Am Acad Dermatol 2002;46:228-41.
  12. Am Fam Physician 2002;66:1899-902.
  13. J Allergy Clin Immunol 2003;111:1153-68.
  14. J Am Acad Dermatol 2004;51:515-25.
  15. Clin Exp Allergy 2004;34:639-45.
  16. Dermatol Clin 2004;22:461-5,ix-x.

Resource
National Eczema Society (UK)
W:www.eczema.org
Eczema Voice
W:www.eczemavoice.com

FAQs

What is new in atopic dermatitis? ›

Recent advances have been made in treatment for pediatric AD. Ruxolitinib has been FDA approved for patients aged 12 years and above, making it the first medicine tested in adolescents aged 12 to 17 years. It can be used for AD patients with mild-to-moderate cases who are not using other medications.

Why is atopic dermatitis increasing? ›

Increased water hardness, exposure to tobacco smoke, and psychological stress may also be arguable byproducts of urbanization and have been associated with AD risk.

What is the most effective treatment for atopic dermatitis? ›

Topical corticosteroids have been the mainstay of treatment for atopic dermatitis flare-ups and are the agents to which other treatments are compared. Calcineurin inhibitors should be used as second-line agents, and, rarely, systemic therapies may be considered in adults.

Is there a permanent cure for atopic dermatitis? ›

There's no cure, but many children find their symptoms naturally improve as they get older. The main treatments for atopic eczema are: emollients (moisturisers) – used every day to stop the skin becoming dry. topical corticosteroids – creams and ointments used to reduce swelling and redness during flare-ups.

When was Cibinqo FDA approved? ›

In January 2022, the FDA approved Cibinqo (abrocitinib), a new oral medication option for AD in adults.

Is abrocitinib approved for atopic dermatitis? ›

Abrocitinib: A New FDA-Approved Drug for Moderate-to-Severe Atopic Dermatitis. Ann Pharmacother. 2022 May 19;10600280221096713. doi: 10.1177/10600280221096713.

Who is most affected by atopic dermatitis? ›

It has been shown that children had the highest prevalence as compared to older age groups. Furthermore, among the over >8 million individuals aged 0 to 99 years, the cumulative lifetime prevalence of atopic eczema was 9.9% and rates of active disease were highest among children and older adults.

Is atopic dermatitis life long? ›

Atopic dermatitis (AD) is the most common type of eczema, affecting more than 9.6 million children and about 16.5 million adults in the United States. It's a chronic condition that can come and go for years or throughout life, and can overlap with other types of eczema.

How many people have severe atopic dermatitis? ›

The study finds that AD occurs in 7.3% of adults in the U.S. Of those affected with the disease, about 40% have moderate or severe symptoms. The purpose of the study, titled Atopic Dermatitis in America, was to: Establish the prevalence of AD in the U.S. adult population.

Is sun good for atopic dermatitis? ›

Most patients affected by atopic dermatitis improve during sun exposure. It has been reported that the change from a subartic/temperate to a subtropical climate for 4 weeks improved significantly skin symptoms and quality of life in children, even for 3 months after return.

How close are we to a cure for eczema? ›

Eczema is a common skin condition affecting up to 20 percent of children and 3 percent of adults worldwide. While there's no shortage of creams and lotions that help alleviate the chronic symptoms of eczema, we still haven't found a cure that can clear it up for good.

What is the fastest natural cure for eczema? ›

This article explores the best natural remedies for eczema.
  1. Aloe vera gel. Share on Pinterest Kutay Bozdogan/EyeEm/Getty Images. ...
  2. Apple cider vinegar. Apple cider vinegar is a popular home remedy for many conditions, including skin disorders. ...
  3. Bleach in the bath. ...
  4. Colloidal oatmeal. ...
  5. Baths. ...
  6. Coconut oil. ...
  7. Honey. ...
  8. Tea tree oil.

What is severe atopic dermatitis? ›

What exactly is severe AD? AD is the most common type of eczema. When this eczema becomes severe, a person has patches of skin that are red, swollen, and unbearably itchy. The patches of AD can weep fluids. Skin infections are common.

Can atopic dermatitis spread? ›

Overview of Atopic Dermatitis

It is a common condition that usually begins in childhood; however, anyone can get the disease. Atopic dermatitis is not contagious, so it cannot be spread from person to person.

What do doctors prescribe for atopic dermatitis? ›

The most commonly used immunosuppressants for atopic dermatitis are cyclosporine, azathioprine, methotrexate, and mycophenolate mofetil.

How long does it take for Cibinqo to work? ›

In a study of 837 people, more people taking CIBINQO with topical steroids and daily moisturizer achieved clear or almost clear skin at 3 months (36% on 100 mg and 47% on 200 mg) vs people taking placebo with topical steroids and daily moisturizer (14%). Not everyone will respond to treatment with CIBINQO.

What are the side effects of Cibinqo? ›

The most common side effects of CIBINQO include common cold, nausea, headache, herpes simplex including cold sores, increased blood level of creatinine phosphokinase, dizziness, urinary tract infection, tiredness, acne, vomiting, mouth and throat pain, flu, stomach flu, bacterial skin infection, high blood pressure, ...

What is Cibinqo Pfizer? ›

CIBINQO is indicated for the treatment of adults with refractory, moderate-to-severe atopic dermatitis whose disease is not adequately controlled with other systemic drug products, including biologics...

What is ruxolitinib cream used for? ›

Ruxolitinib cream, to be sold under the name Opzelura, is the first topical Janus kinase inhibitor cream for the treatment of atopic dermatitis. The first topical Janus kinase (JAK) inhibitor cream for the treatment of atopic dermatitis (AD) was approved this week by the FDA.

Is there pills for eczema? ›

DUPIXENT® (dupilumab) is a prescription medicine used to treat people aged 6 years and older with moderate-to-severe atopic dermatitis (eczema) that is not well controlled with prescription therapies used on the skin (topical), or who cannot use topical therapies.

When is Etrasimod available? ›

Etrasimod is also being tested in a pivotal program for Crohn's disease, and a phase 3 study for atopic dermatitis will kick off later this year. Readouts for phase 2 programs in eosinophilic esophagitis and alopecia areata are expected at the end of 2022 or early 2023.

How effective is Opzelura? ›

At the end of the 24-week treatment period, 30% of Opzelura patients had at least 75% improvement in the facial Vitiligo Area Scoring Index, compared with 10% of placebo patients.

How long does Opzelura take to work? ›

Reductions in itch began as early as 12 hours after first application.

What is the name of the new eczema pill? ›

DUPIXENT is a prescription medicine used: to treat adults and children 6 months of age and older with moderate-to-severe atopic dermatitis (eczema) that is not well controlled with prescription therapies used on the skin (topical), or who cannot use topical therapies.

What is the difference between Adbry and Dupixent? ›

Both Adbry and Dupixent (dupilumab) are biologics FDA-approved for moderate to severe atopic dermatitis. Adbry has a different antibody target than Dupixent. Learn more about Dupixent here. Clinical trials for other biologics for AD are currently underway.

Who should not use Opzelura? ›

The use of OPZELURA along with therapeutic biologics, other JAK inhibitors, or strong immunosuppressants such as azathioprine or cyclosporine is not recommended. It is not known if OPZELURA is safe and effective in children less than 12 years of age with atopic dermatitis.

When will ruxolitinib cream be available? ›

The FDA previously approved ruxolitinib for mild to moderate atopic dermatitis (eczema), in the fall of 2021.

Can Opzelura be used long term? ›

Do not use it for longer than 8 weeks in a row or use more than 60 grams per week unless directed to do so by your doctor. Tell your doctor if your condition does not get better after 8 weeks of using this medication or if your condition gets worse at any time.

Is Opzelura safe for face? ›

Apply OPZELURA directly to the affected areas of the skin. Can be applied on any areas where you have eczema, even sensitive ones like the face. OPZELURA is for use on the skin only.

Is Opzelura cream a steroid? ›

Your healthcare provider should watch you closely for signs and symptoms of TB during treatment with OPZELURA. It is not a steroid, pill, ointment or injection. It's a treatment that targets eczema at a key source. OPZELURA first became available for people with eczema in 2021.

Is Opzelura cream over the counter? ›

OPZELURA is a prescription medicine used on the skin (topical) for the short-term and non-continuous chronic treatment of mild to moderate eczema (atopic dermatitis) in non-immunocompromised adults and children 12 years of age and older whose disease is not well controlled with topical prescription therapies or when ...

Is there a daily pill for eczema? ›

RINVOQ is a once-daily pill that can help treat your moderate to severe eczema and deliver symptom relief. It's even proven effective without topical steroids.

Is there an oral pill for eczema? ›

Oral corticosteroids are powerful anti-inflammatory medications that often relieve symptoms of dermatitis or eczema, including itching, redness, and rash, within hours or days.

Has eczema been cured? ›

Natural Eczema Treatment and Prevention

Unfortunately, since eczema is a chronic condition caused by an inflammatory immune response, it can't be permanently cured. But it can be treated and managed through prevention strategies – primarily through identifying and avoiding triggers.

What is better than Dupixent? ›

Adbry, Cibinqo, Eucrisa, Opzelura, and Rinvoq are some Dupixent alternatives for atopic dermatitis. Get the full list here. Eczema is a condition of inflamed skin that causes symptoms such as itching, dry skin, rashes, scaly patches, blisters, and skin infections.

Is there a cheaper alternative to Dupixent? ›

There is currently no generic alternative to Dupixent. It may be covered by your Medicare or insurance plan, but some pharmacy coupons or cash prices could help offset the cost.

How long can you stay on Dupixent? ›

Dupixent Safe, Effective Up to Four Years in Adults With Moderate-to-Severe Atopic Dermatitis. Safe and effective long-term treatment is important for stable disease control in atopic dermatitis.

Videos

1. Emerging treatments in atopic dermatitis (eczema) – webinar held 7 June 2022
(North Western Melbourne Primary Health Network)
2. Atopic Dermatitis: A New Oral Medication
(Mount Sinai Health System)
3. Atopic Dermatitis: Beyond Scratching the Surface
(ExchangeCME)
4. ATOPIC DERMATITIS TREATMENT | New Nurse Practitioners
(Real World NP)
5. The New Paradigm in Atopic Dermatitis Treatment: Landing Page
(Annenberg Center for Health Sciences)
6. The New Paradigm in Atopic Dermatitis Treatment: Line 8 Stop 7 Nemolizumab
(Annenberg Center for Health Sciences)
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