Journal Club: Dupilumab and Atopic March

Dr. Lisa Swanson:
Hi, everybody and welcome to a Practical Dermatology Atopic Dermatitis Journal Club. My name is Lisa Swanson, and I'm a dermatologist and pediatric dermatologist in Boise, Idaho. I work at Ada West Dermatology in St. Luke's Children's Hospital, and I'm joined today by my friend, hero, mentor, Dr. Peter Lio. Welcome, Dr. Lio. Do you want to tell the crowd who you are?

Dr. Peter Lio:
Yes. Well, all that right back at you. I reflect this same sentiment and emotions. I'm Peter Lio. I'm a dermatologist in Chicago. I have my own practice called Medical Dermatology Associates, and I have also been obsessed with atopic dermatitis for quite some time.

Dr. Lisa Swanson:
Yes, who hasn't? And now is a great time to be obsessed with atopic dermatitis. It's kind of like being a Chicago Bears fan, Peter. There are a lot of bad years, and then all of a sudden, you get a good year and you're glad you were a fan the whole time. Because atopic dermatitis is having a moment, and it's been having a moment for the past several years. And that's really exciting because we really struggled with significant atopic dermatitis for years and years before we had some advances.

And today we're going to be talking about an article about dupilumab and the atopic march. So we know that atopic dermatitis is associated with an increased risk of the atopic triad diagnoses like allergies and asthma. And it's more than a triad these days. There's now EoE. And we also know that dupilumab is an approved treatment for some of these things, approved for asthma down to six, approved for EoE down to age one.

And what we're learning more recently is that early initiation of dupilumab for the atopic dermatitis might actually thwart the atopic march. I was so excited when I read this article. Peter, what did you think? Were your eyes wide open, super jazzed?

Dr. Peter Lio:
100%. I mean, right? This is the dream. So obviously curing the disease would be amazing, but preventing it would be even better. And this has the potential to prevent comorbidities that we know affect so many patients and have such a huge impact, and with a medicine that we already use and is already approved.

It's one thing to hear about, "In the future, we're going to understand these things." It's quite another for someone to say, "Hey, the thing that actually has been helping many of your patients might actually be doing more good." And frankly, it's refreshing to hear something good instead of, "Oh, it's also doing something terrible."

Dr. Lisa Swanson:
Yes, definitely, definitely. So this article that we're discussing today showed a reduction in risk for allergies and asthma in patients started on dupilumab for their atopic dermatitis. And we were all thrilled to see this. Oh my gosh, disease mitigation, that makes us all so happy.

And it's a medication, like Peter, you said, we're already using, and it's approved down to the age of six months old for our patients with atopic dermatitis. The one question I had after reading the article was how early do we have to intervene to show this reduction in risk? I think this is still an unanswered question for us. What do you think, Peter?

Dr. Peter Lio:
I totally agree, and I think part of the question for me too is, so I think you're with me on this to some degree, that even for established atopic dermatitis, it's already existing, it's already raging, when we treat it well, certainly I think with the biologics, but maybe even with other treatments too, to some degree we can break that vicious cycle of disease.

And some patients, at least a minority for sure, but a group of them can get significant modification or what appears to be modification of the disease, meaning before they needed something very powerful, but now we might even be able to decrease, to increase the interval of the medication or even stop the medication and they will remain improved, relatively speaking.

So that's true with atopic dermatitis to some degree. Is it even possible that some of the patients who've already developed asthma or food allergy or allergic rhinitis or EoE, that we might see a similar modifying effect even if it exists? So that would be interesting just to know. You're never too late potentially for some patients, which is exciting. But then your question's really important, do we have to be before it starts and when is it really starting?

Because we might not see EoE until they're 12 or 14 or even adulthood, but maybe the seeds were planted in the first six months of life. So what if we find out that we need to be treating from the very beginning in order to get this? And I think those are important unanswered questions.

Dr. Lisa Swanson:
And while I was so excited to read the article, I wasn't exactly surprised because our newest understanding of the relationship between atopic dermatitis and allergies is that the eczema might actually be opening the door to these allergies. That aerosolized food particles can enter through the skin's broken barrier, triggering an abnormal immunologic response, which becomes allergy. And so the theory becomes if you can treat the atopic dermatitis, potentially you can prevent the allergies. Any comments on that?

Dr. Peter Lio:
I think this is the most important narrative of our time. We've really seen this idea that the transcutaneous sensitization, as you beautifully describe it, is so important. So it really follows that if we can heal that skin barrier, if we can break this, then we should be able to, in theory, at least for some allergens, maybe this isn't universally true, I'll give you that, I'll grant you that, but I think that for some patients we think this is an important mechanism. And thus for me, I've used it for families who are very treatment hesitant.

I'll say, "I know that you don't want to do anything, and I understand that maybe the eczema isn't bad enough that you feel like you can't tough it out. I don't recommend that, but think about these other potential issues." And sometimes when you bring that up, families snap to attention and say, "Okay, I hear what you mean. It's not good to walk around with damaged, open, oozy skin for so many reasons, but potentially even for these comorbidities that can develop because of that."

Dr. Lisa Swanson:
I've had the same experience. In fact, I had a six-month-old patient that came to see me with moderate atopic dermatitis and dad has atopic dermatitis, asthma, food allergies, EoE. He's on dupilumab as an adult. And so I shared this article with them and I said, "We can try some topicals at first to control the atopic dermatitis, but we might want to consider something like dupilumab, not only to help with your child's atopic dermatitis.” But jeez Louise, I turned to the dad and I said, "If we could go back in time and intervene and potentially prevent all that you've had to deal with through your life, would you want to do that, kind of a ‘Back to the Future’ kind of moment?" And so we did try topicals at first. But when they came in for follow-up, they were ready to consider dupilumab.

Dr. Peter Lio:
It's powerful. And again, we wouldn't be using this. This isn't for fun. This isn't a cosmetic treatment. And we know it's powerful and we know it's expensive, but we're talking about serious ramifications, repercussions on kids' lives. I think it's a worthwhile thing to at least discuss. Maybe not every family is ready, but I think there are increasingly people realizing that this is something preventable that we could do. And if we can make an intervention like this, it might not even be forever. It might just be a few years until we're out of a danger period and then we can stop the medication.

Dr. Lisa Swanson:
So true. So true. Well said, Dr. Peter Lio. Thank you so much for joining us today, you guys. I hope you got something out of this Atopic Dermatitis Journal Club.