Dr Steve Feldman on How Adverse Event Risks Influence Atopic Dermatitis Treatment Selection

Steve Feldman, MD, PhD, dermatology professor at Wake Forest University School of Medicine, explains how adverse event risks influence atopic dermatitis (AD) treatment selection. He also highlights emerging AD treatments that provide effective itch control with minimal adverse event risks.

This transcript has been lightly edited for clarity.

Transcript

How do the risks of adverse events influence the selection of treatments for patients with AD?

That's a great question because atopic dermatitis, if it's bad, is commonly taken care of by dermatologists. Now, dermatologists are not the biggest risk takers in the world, we didn't go into neurosurgery. When we give people a cream for their acne, if that cream might cause dryness, we get nervous. So, we like to minimize adverse events, and I think that's why we tend towards using the safer treatments.

Actually, there have been head-to-head trials showing that some of the JAK [Janus kinase] inhibitors are 4 times as effective at getting people completely clear than dupilumab is. But I still start with dupilumab because I don't want to take the risk of the side effects. Dupilumab gets people very happy most of the time—the great majority of the time. Like, 80% of the time, they're very happy with the efficacy and safety of that treatment. Then, if they're not happy with it, I would go to the JAK inhibitors that potentially have more risks.

Can you discuss any emerging treatments that show promise in providing effective itch control with minimal adverse events?

Our understanding of the immune system is always improving, and that gives us new targets for interfering with the inflammation that's causing atopic dermatitis. A number of drugs are in development that affect the immune system and will make atopic dermatitis better, but most of them, if not all of them, are not any more specific than dupilumab; at best, they might be about as specific as dupilumab.

It'd be nice to have, but if they require cardiac monitoring, or there's a risk of infection or cancer, I'm not going to be too excited because I'm so anchored on treatments that are very, very safe, like dupilumab.

There is a signaling molecule in the immune system, interleukin-31, that seems to be directly responsible for itch. There's a drug coming out that blocks interleukin-31. That looks like it'd be a very effective way to treat itch, both for patients with atopic dermatitis and, potentially, for people who have other conditions that cause itch, like prurigo nodularis.

We have a lot of patients who itch and may have dry irritable skin. I don't know that we always call it atopic dermatitis, but they might have poor kidney function or poor liver function, they have itch. I think an interleukin-31 blocker might be a really good treatment for itch for those patients, for old people, who maybe they do have a form of atopic dermatitis that just causes dry skin and itch. An interleukin-31 blocking drug, I think nemolizumab is the name of it, may be a very good option that would be nice to add to the options we can offer to patients.