Clinical Edge Journal Scan

Commentary: Three New AD Treatments and a Study of Food Allergy, May 2023

Dr. Feldman scans the journals, so you don’t have to!

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Steven R. Feldman, MD, PhD

Silverberg and colleagues present the results of two phase 3 clinical trials of lebrikizumab. Considering what we already know about interleukin 13 (IL-13) blockade with dupilumab and tralokinumab, it isn't surprising that lebrikizumab was effective and had few side effects. The Investigator Global Assessment (IGA) success rates in the 40% range seem roughly similar to those of dupilumab. While "40% success" doesn't sound great, real-life success rates are much higher — at least with dupilumab — than you'd expect on the basis of this IGA success rate. A minor limitation of dupilumab treatment is the side effect of conjunctivitis (minor in that most patients can be treated with saline eye drops); conjunctivitis was also seen with lebrikizumab in these phase 3 studies. Lebrikizumab appears to be another good tool in our toolbox for patients with moderate to severe atopic dermatitis, but it's not a quantum leap forward in atopic dermatitis management.

Torrelo and colleagues described the efficacy and safety of baricitinib in combination with topical corticosteroids in pediatric patients with moderate to severe atopic dermatitis. At the high dose of 4 mg daily, the IGA success rate was about 40%, similar to what we expect for adults treated with dupilumab and less than what we might expect with upadacitinib.

Studies have already been done on efficacy and safety of baricitinib in adults with atopic dermatitis. But baricitinib is indicated for the treatment of adult patients with severe alopecia areata and is not currently indicated as a treatment for anyone with atopic dermatitis, at least not in the United States. At this time, I think the most useful aspect of Torrelo and colleagues' findings is being able to tell our adult patients with alopecia areata that baricitinib was safe enough that they could test it in children as young as 2 years old with eczema.

Perälä and colleagues' report comparing topical tacrolimus and topical corticosteroids (1% hydrocortisone acetate or, if needed, 0.1% hydrocortisone butyrate ointment) in young children with atopic dermatitis is fascinating. They saw patients back at 1 week and followed them for 3 years. In just 1 week, both groups had massive and similar improvement in their atopic dermatitis, and that improvement continued throughout the study. Here are some take-home points:

  • Atopic dermatitis responds rapidly to low-to-medium–strength topical steroids.
  • Bringing patients back at 1 week may have been a critical aspect of this study, as adherence to topicals can be abysmal; bringing patients back at 1 week probably enables them to use their treatment much better than they would otherwise.
  • If we need a nonsteroidal topical, we have an excellent one available at low cost in the form of topical tacrolimus.

Perälä and colleagues also did this study to see whether good treatment of atopic dermatitis in these young children would have long-term benefits on atopic airway issues. Because the researchers didn't have a placebo group (and considered it unethical to have one), we cannot tell whether the topical treatment provided any benefit in that regard.

Yamamoto-Hanada and colleaguesexamined whether "enhanced" topical steroid treatment would prevent food allergy in children with eczema compared with standard topical steroid treatment. Perhaps a better word than "enhanced" would be "aggressive." The enhanced treatment entailed having infants receive alclometasone dipropionate for the whole face and betamethasone valerate for the whole body except face and scalp. While the researchers saw a reduction in egg allergy (from roughly 40% to 30%), they also saw reduced body weight and height. A key take-home message is that with extensive use of topical steroids, we can see systemic effects.

Recommended Reading

Baricitinib shows promise in pediatric patients with moderate-to-severe atopic dermatitis
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Baricitinib allows flexibility in dosing regimens up to 104 weeks in moderate-to-severe atopic dermatitis
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Topical tacrolimus and corticosteroids show similar efficacy and impact on airways in childhood atopic dermatitis
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Maternal atopic dermatitis linked with the risk for childhood- and adult-onset atopic dermatitis
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Abrocitinib offers comparable efficacy between adults and adolescents with moderate-to-severe atopic dermatitis
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