A Guidelines-Based Recommendations Algorithm for Atopic Dermatitis

Christopher Bunick, MD, FAAD:

It's very important to understand the treatment algorithms for moderate to severe atopic dermatitis. Let's focus on an American Academy of Dermatology Guidelines-Based Recommendations algorithm. Right now, and these guidelines were just updated in the last few weeks, we have four approved and recommended biologics for atopic dermatitis.

This includes Dupilumab, Tralokinumab, Lebrikizumab, and Nemolizumab. Each of these work by a little bit different mechanism. We know that Dupilumab targets interleukin-4 receptor alpha. Lebrikizumab and Tralokinumab are targeting the cytokine interleukin-13, but from a different molecular perspective. They're 180 degrees opposite of each other on binding IL-13. And then Nemolizumab, which targets the interleukin-31 receptor.

We also have two FDA-approved therapies that are oral systemic Janus kinase or JAK inhibitors. These are Upadacitinib and Abrocitinib. When we put all that together, the American Academy of Dermatology in its guidelines has said that all six of these therapies have the strongest recommendation for use.

Notice what's not in that strongest recommendation for use, and that's oral corticosteroids. We, as a specialty, have long used oral corticosteroids to treat atopic dermatitis because it was convenient, it was fast, it was easy. And let's be honest, steroids have a broad immunosuppressive effect that can be effective.

But the American Academy of Dermatology, as well as numerous atopic dermatitis experts, have said that systemic corticosteroids are conditionally recommended against. Despite that, there has been some recent research showing that one in five moderate to severe atopic dermatitis patients still receive oral systemic corticosteroids.

And when they get those steroids, they are receiving it about a third of the time for over 90 days. When we are giving chronic oral corticosteroids to our AD patients at that level and frequency, this is against the AAD guidelines and against using more targeted, specific, more efficacious, and safer therapies than oral corticosteroids.

When you have a patient in your office, whether it's a new patient for the first time getting an atopic dermatitis treatment or a patient that has a major flare and wants therapy quickly, don't reach for oral corticosteroids. This is against our guidelines.

What I'd like you to do is focus on those six advanced systemic therapies that we do have and that are recommended by the American Academy of Dermatology for the treatment of moderate to severe atopic dermatitis. They are targeted, they are effective, they are safe, and they are better for our patients than constantly reaching for oral corticosteroids.