Journal Club: Updated Clinical Practice Guidelines

Dr. Neal Bhatia:
Hi, I am Dr. Neal Bhatia, I'm Chief Medical Editor of Practical Dermatology. Happy New Year and Happy Holidays. I'd like to springboard to my newest member of the family, Dr. Lisa Swanson. Elizabeth, Happy New Year.

Dr. Elizabeth Swanson:
Yes, Happy New Year. Yay, 2025, here we come.

Dr. Neal Bhatia:
Here we come, that's right. With 2025 comes some new drugs, which is going to be great. Some old approaches to new diseases or vice versa, which we actually need the newer approaches but also we need to go back to fundamentals, and fundamentals starts with modifying process. So with some of the new advances, you were a little bit more in tune to the guidelines of some of the newer therapies for atopic dermatitis with the advent.

And by the way, this is an episode of the Atopic Dermatitis Journal Club, I forgot to bring that up. And with that, we're going to just talk about some of the newer therapies as well as some new approaches. But tell us a little bit about what you've discovered in reviewing some of the newer guidelines and approaches, especially from your angle as a peds derm as well.

Dr. Elizabeth Swanson:
Yeah, I mean, I think the biggest thing is that anytime new guidelines are released within two or three months, they need to be updated because we are in the midst of this atopic dermatitis treatment revolution that is a privilege to be a part of and makes me excited to go to work every day because we have so many more tools in our toolbox to help our patients. And so these guidelines that were just released, they don't include some of our other newer tools like lebrikizumab, tapinarof, approved down to age two. Roflumilast approved last summer down to age six, and then turning back to lebrikizumab approved down to 12 for moderate to severe atopic dermatitis. And so it seems like it took forever for us to get new guidelines and now anytime we do, they're quickly replaced with all these new drugs and new tools that we have. It's pretty awesome.

Dr. Neal Bhatia:
Which is nice because the one thing now we can put on the back burner are steroids. We can maybe learn how to use steroids properly and we can maybe put them into context of, "Yeah, let's put out the fire quickly. Let's not make patients steroid dependent." And the two big ones topically you mentioned that go along with topical ruxolitinib as approved, which topical tapinarof and roflumilast, we can think about breakthrough, we can think about surface areas, we can think about eyelids, all the places where patients were not willing to put stuff on.

Dr. Elizabeth Swanson:
I was just going to say the really nice thing about the approvals of roflumilast and tapinarof is that they do not include a limitation of use. We know that topical ruxolitinib, which is awesome, such an effective agent, but it's saddled with this limitation of use to not combine it with other systemics and biologics, which can be a big bummer for the patient who's on something like dupilumab and just needs a little bit of something for touch-up paint, and the insurance companies give us a hard time wanting to combine it with topical rux. With tapinarof and roflumilast, we don't have to worry about that limitation of use and so I've really found that helpful in my practice.

Dr. Neal Bhatia:
Yeah, that's good. Touch-up paint is a good one, that's a smart one.

Dr. Elizabeth Swanson:
Right?

Dr. Neal Bhatia:
So given that restriction with JAK inhibitors and especially with oral JAK inhibitors, not using a topical, now at least we can play a little bit of roulette and say, "All right, let's mix and match different topicals, different systemics, a breakthrough in all the areas that are stubborn." But what do you see coming in the crystal ball? Where does '25 bring us in terms of what's coming and what we should be thinking about?

Dr. Elizabeth Swanson:
So I'm hopeful that we finally see the age indication for topical ruxolitinib go down to age two. I have been not so patiently waiting for this for about a year because the trials were really completed over a year ago, but we're still awaiting the age indication to go down to two. I am interested to see how our new biologics stack up to dupilumab and to our oral JAK inhibitors. I'm interested to see the real life of lebrikizumab, the real life of nemolizumab. I'm excited for a couple topicals on the horizon with delgocitinib, a topical pan-JAK. And with difamilast, another phosphodiesterase 4 inhibitor. So we're in the era—to quote Taylor Swift, Dr. Bhatia—we're in the era of atopic dermatitis right now.

Dr. Neal Bhatia:
There you go, my wife being the Swifty that I know you are, you guys will speak that same language.

Dr. Elizabeth Swanson:
Yes, yes.

Dr. Neal Bhatia:
But we still have a blank space, no pun intended, a lot of different approaches. And again, a lot of dermatologists just need to shake it off when they are not comfortable with what they're afraid of, right?

Dr. Elizabeth Swanson:
Look at you, you try to claim you're not a Swifty.

Dr. Neal Bhatia:
Listen, I have SiriusXM in the car, I can claim everything as long as I can change the channel fast enough. But to that same end how do we, again, you and I have talked about this many a times, how do we get our colleagues to just get over whatever they say they're not comfortable about?

Dr. Elizabeth Swanson:
Yeah, I think one of the biggest challenges is that if a patient comes in, especially an established patient, long history of atopic dermatitis, they've been on topical steroids, it's a lot easier during that relatively short appointment to just refill their topical steroids.

Dr. Neal Bhatia:
Yeah.

Dr. Elizabeth Swanson:
But I would encourage folks to take the time to tell them about these new wonderful therapies because these steroid-free options are what our patients have been wanting for years, and years, and years. And once you have your spiel down to quickly cover what's new, it really doesn't take that much time. And patients are so excited to hear about these new options for them.

Dr. Neal Bhatia:
Oh, completely. And especially when they're used to the tubs of triamcinolone, we could probably call them the antihero, how about that?

Dr. Elizabeth Swanson:
You just keep doing it. I am struggling to come up with Taylor Swift lyrics and here you are, they're just spitting out of you.

Dr. Neal Bhatia:
That's terrible. All right, so any last pros before we sign off and we can pick this up again because I know you and I are going to be getting to do this a lot, which will be great.

Dr. Elizabeth Swanson:
Yeah. I think this is the golden era of treating atopic dermatitis and everybody should be excited to see those patients with moderate to severe, even mild to moderate atopic dermatitis. I remember years ago when we did not have as many options, if I had a few tough eczema patients, those days were hard days. And I would go to my car and cry like Ryan Gosling in Fall Guy to Taylor Swift all too well. Yeah, I would do that.

But now I'm so excited to see the patients with bad atopic dermatitis because it's like, oh my gosh, the options we have, we can do so much life changing in our day-to-day practice. And I realize it takes a little bit more time in the clinic, but it's worth it.

Dr. Neal Bhatia:
It's worth it.

Dr. Elizabeth Swanson:
Your patients will be so grateful.

Dr. Neal Bhatia:
Give them that extra few minutes, have them try the samples in front of you, have them demonstrate that they can do the shots or take the pills in front of you, all of that. And we have to remind them, too, that atopic dermatitis is not just winter time and they could have a cruel summer also. So needless to say, I totally had to throw that-

Dr. Elizabeth Swanson:
Do you have these written down? Are they in front of your screen?

Dr. Neal Bhatia:
I know, right? I should probably have a playlist in front of me. But Lisa, all right, thank you, this was good and we're going to have another episode of Atopic Dermatitis Journal Club very soon. Thanks everybody and enjoy 2025, it's going to be fun.