Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, Dr. Katrina Abuabara will discuss considerations when using systemic treatments in special populations of adults with atopic dermatitis. Dr. Abuabara is an Associate Professor of Dermatology at University of California San Francisco School of Medicine, and she spoke on this topic at the 2025 American Academy of Dermatology Annual Meeting. Let’s hear from her now.
Dr. Abuabara:
There are four main categories of systemic treatments we think about. One is phototherapy. So that can be narrowband UVB or broadband UVB phototherapy, or PUVA, where the patient takes a photosensitizing agent. We think about the traditional systemics, which are more broadly immunosuppressive—things like methotrexate, azathioprine, cyclosporine, mycophenolate mofetil. With the new biologics, the one that’s been on the market longest is dupilumab, and now we have tralokinumab and lebrikizumab, which are in a similar category. And finally, the last category, there are the JAK inhibitors, and the ones that are currently approved for atopic dermatitis in the United States are upadacitinib and abrocitinib.
Atopic dermatitis is not just a skin disease of kids anymore. It’s a systemic disorder affecting people of all ages, so it’s really important to think about the comorbidities. So asthma is a common one. There is some evidence that treatments like dupilumab can help with asthma as well. I see that in some of my patients, so that may be a reason to think about, for example, phototherapy probably doesn’t make much of a difference for asthma, so you might think about the double hit.
With the other conditions, it’s important to think about both the risks and the benefits. So there’s actually a little bit of research on JAK inhibitors and metabolic syndrome. Early research suggests they may reduce inflammation and help with some components of metabolic syndrome. With that being said, there’s also an increased cardiovascular risk with metabolic syndrome and with the JAK inhibitors, so I would urge caution with that category of drug in patients with metabolic syndrome, for example.
Depending on which special population we think about, you may be careful about some drugs, and because of the monitoring requirements, there may be some treatment categories that you’re more reticent to use. So when I think about any treatment for a patient, I want to understand their goals. Do they want clear skin? Do they want to be less itchy? Do they want to sleep better? Or maybe they want to minimize the number of pills they take or not have to give themselves injections, or maybe they can’t handle any more physician visits. For example, one category of special populations are pregnant women. Sometimes they’re already doing a lot of prenatal monitoring. They don’t want to come in regularly for extra lab draws if I put them on a traditional systemic that requires frequent monitoring or a JAK inhibitor. Maybe they want something that has fewer injections and fewer lab draws. So those are all things to consider.
Our phototherapy can be great for patients that have a lot of coexisting conditions, but logistically, it’s more challenging because patients have to come in two to three times a week or be able to use a phototherapy light at home. That’s possible but can require more logistical coordination.
I think it’s really exciting that we have a lot of new treatment options now, and there’s more coming along. A really important thing to note is that most clinical trials are designed to study people who have just atopic dermatitis. Generally, they exclude patients with other pre-existing conditions or patients who are older, so for that reason, the results from the trials aren’t always applicable to the patients that wind up in our office and have multiple comorbidities.
We try to get as much information as we can from the clinical trials. Sometimes there’s sub-analyses done, for example, in the older patients that are in the trials after the study, but they’re not really designed to understand the efficacy and safety in the same way a carefully designed trial would be. One thing that’s important is to look for trials—for example, post-marketing ones—that might include a broader range of patients and be more generalizable, and then as more time goes on, we get more and more data on real-world use. So there are adverse event-reporting databases that can help us to understand safety profiles, so if you’re out there and using a drug and you see an adverse event, it’s really important to register it with the FAERS because that can really give us good data on what we should be looking for and what we should be careful about.
Announcer:
That was Dr. Katrina Abuabara discussing the use of systemic treatments in special populations of adults with atopic dermatitis. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!
