New and Upcoming Treatment for Vitiligo, Atopic Dermatitis

Atopic dermatitis (AD) and vitiligo are both skin conditions that require long-term treatment through various forms of medication. A panel discussion that took place during the 2023 Fall Clinical Dermatology Conference featured segments on what doctors need to know about both conditions going forward.

Progress in Vitiligo Treatment

The panel featured a segment on vitiligo that was led by Seemal R. Desai, MD, FAAD, clinical assistant professor in the Department of Dermatology at the University of Texas Southwestern Medical Center.

“Now more than ever in 2023 is an incredible time for us to talk about this disease,” he said. “Five years ago when I was at this conference talking, it was all anecdotal because none of it was FDA approved…Now it’s an incredible time, there’s more and more happening.”

The worldwide prevalence of vitiligo is somewhere between 1 in 250 and 1 in 50, with likely thousands of patients left untreated. Each sex is equally affected and more than half of the affected patients show signs before they are 20 years of age. Desai started by going through different categories of treatment, the first being topical therapy, the second of systemic therapeutic, and the last being procedural.

When it comes to topical therapy there are treatments including steroids, vitamin D analogues, and calcineurin inhibitors. Vitiligo is not a mono-therapy disease. Although improvement has been made with mono-therapy topicals, the combination of phototherapy, oral antioxidants, and oral and topical medications together are what’s needed, according to Desai.

Stabilizing vitiligo is the most important thing before starting on continued treatment. Giving a patient with unstable vitiligo a regular oral or topical medication will lead to ineffective treatment. Unstable vitiligo can be determined by patients getting new lesions or if they have deep pigmentation on their fingertips and toes. Systemic steroids have been shown to stabilize vitiligo and there’s promising data for oral janus kinase (JAK) inhibitors to treat unstable vitiligo. These treatments can include oral mini-pulse therapy and dexamethasone 4 mg daily. Desai said that he’s also a fan of antioxidants in vitiligo such as polypodium leucotomas.

Desai said that there’s a lot of excitement about JAK inhibitors being used for vitiligo treatment, as the JAK inhibitors can shut down the interferon that causes vitiligo. He presented 1 patient in the study he did that had 90% improvement in the head and neck with topical ruxotinib. Oral JAKs can also be used to treat vitiligo and phase 3 trials are currently being conducted on their efficacy. Povorcitinib has also shown promising results in 45 mg and 75 mg doses. Stabilizing patients may also be faster when using once daily JAK inhibitors.

Desai also emphasized that JAK inhibitors do not need phototherapy for them to work. “JAK inhibitors work better in many circumstances with the fertilizers helping the lawn and flowers grow of UV light, but it is not mandatory,” he said.

Last he went over procedural therapies. An FDA approved treatment exists called ReCell that allows doctors to do melanocyte and keratinocyte transplantation in the office. This involves using lasers to identify the recipient site and using a durablade to take a small sample of cells. Durable pigmentation has been a result of this treatment.

“I think now more than ever is an incredibly time for vitiligo. We’ve talked about topicals, orals, and procedural therapy but I think there’s lots more on the horizon,” said Desai. “So please give your patients hope that more treatments are left to come.”

Atopic dermatitis. Red, itchy hands with blisters seen by a dermatologist | Image credit: Rochu_2008 - stock.adobe.com

Atopic Dermatitis Can Be Treated Effectively

John Koo, MD, from the University of California San Francisco Department of Dermatology, gave a presentation of his own about treatments in AD. His presentation focused on diagnosis, efficacy, and safety.

AD spectrum disorder is a concept that is endorsed by key opinion leaders in AD and psoriasis. What this means, said Koo, is a huge variation in physical presentation with differences not just in age or ethnic group but even on different parts of the same person’s body. Doctors should ask questions about other rashes that a patient has had in the past as well as personal or family history of eczema, asthma, or food allergies.

Dupilumab can be used to treat chronic pruritus even when no visible rash or inflammation is seen. In a Phase 3 study of prurigo nodularis, dupilumab worked well for the condition even when 57% of the subjects were deliberately chosen due to their lack of visible rash or inflammation. It appears, Koo said, to work through the nervous system. Chronic itch is due to both inflammation and neural hyperreactivity. Dupilumab and JAK inhibitors could help to reverse the itch-scratch cycle by reversing the neurological hyper reactive state.

JAK inhibitors have been proven to work very fast and very well, with upadacitinib having better results than dupilumab in 16 weeks when measuring Eczema Area and Severity Index (EASI). Abrocitinib has also been found to be mor eeffective in improving the EASI-75 score compared with dupilumab in 12 weeks of treatment.

“Black box warnings in both of these 2 medications are not evidence based. None of them,” said Koo.

Although the boxed warnings warn of serious infections that can lead to death, no one in the phase 3 clinical trials for abrocitinib or upadacitinib have died of serious infection and the highest dose for both only had half of the serious infection rate of placebo. This includes tubuerculosis which has not been reported in either medication despite it being included in the black box warning. There has also been no known correlation between mortality and either JAK-inhibitor.

The evidence-based side effects have included acne, nausea, headache, and herpes simplex/herpes zoster. Patients who use JAK inhibitors for dermatology have a much lower risk of having severe adverse events compared with rheumatoid arthritis patients who also use JAK inhibitors. Patients who were aged 65 years and older and were smokers had an higher risk of adverse events due to JAK inhibitors. This is why patient selection is critical.

“Healthy, young, non-smoker, that’s who we should go for,” said Koo.

Koo concluded by saying that AD spectrum disorder is equivalent to an undercurrent of AD. Reversing the itch-scratch cycle through neurointervention could be a key way to treat AD when treated with dupilumab and JAK inhibitors, which have been found to be safe and effective in patients with AD.