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Atopic dermatitis decreases lung function in infants
Key clinical point: Infants with atopic dermatitis (AD) experience significant bronchial obstruction regardless of disease severity, food sensitivity, and a history of recurrent wheezing.
Major finding: Tidal breath analysis revealed that the AD vs control group had significantly lower time to peak tidal expiratory flow (TPTEF; P = .001), exhaled volume to peak tidal expiratory flow (VPTEF; P = .001), TPTEF/expiratory time (P < .001), VPTEF/total expiratory volume (P < .001), expiratory flow when 25% of tidal volume remains in the lungs (P < .001), and respiratory rate (P = .007), with no differences observed within the AD group when these parameters were compared based on disease severity, food sensitivity, and a history of recurrent wheezing (all P > .05).
Study details: This prospective cross-sectional study included 150 infants aged 0-3 years with AD and 80 control infants of similar age without chronic disease, acute or chronic infection, history of prematurity, developmental delay, neurometabolic disease, or atopy.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Koksal ZG and Uysal P. Beyond the skin: Reduced lung function associated with atopic dermatitis in infants. J Allergy Clin Immunol Pract. 2023 (Jul 3). Doi: 10.1016/j.jaip.2023.06.055
Key clinical point: Infants with atopic dermatitis (AD) experience significant bronchial obstruction regardless of disease severity, food sensitivity, and a history of recurrent wheezing.
Major finding: Tidal breath analysis revealed that the AD vs control group had significantly lower time to peak tidal expiratory flow (TPTEF; P = .001), exhaled volume to peak tidal expiratory flow (VPTEF; P = .001), TPTEF/expiratory time (P < .001), VPTEF/total expiratory volume (P < .001), expiratory flow when 25% of tidal volume remains in the lungs (P < .001), and respiratory rate (P = .007), with no differences observed within the AD group when these parameters were compared based on disease severity, food sensitivity, and a history of recurrent wheezing (all P > .05).
Study details: This prospective cross-sectional study included 150 infants aged 0-3 years with AD and 80 control infants of similar age without chronic disease, acute or chronic infection, history of prematurity, developmental delay, neurometabolic disease, or atopy.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Koksal ZG and Uysal P. Beyond the skin: Reduced lung function associated with atopic dermatitis in infants. J Allergy Clin Immunol Pract. 2023 (Jul 3). Doi: 10.1016/j.jaip.2023.06.055
Key clinical point: Infants with atopic dermatitis (AD) experience significant bronchial obstruction regardless of disease severity, food sensitivity, and a history of recurrent wheezing.
Major finding: Tidal breath analysis revealed that the AD vs control group had significantly lower time to peak tidal expiratory flow (TPTEF; P = .001), exhaled volume to peak tidal expiratory flow (VPTEF; P = .001), TPTEF/expiratory time (P < .001), VPTEF/total expiratory volume (P < .001), expiratory flow when 25% of tidal volume remains in the lungs (P < .001), and respiratory rate (P = .007), with no differences observed within the AD group when these parameters were compared based on disease severity, food sensitivity, and a history of recurrent wheezing (all P > .05).
Study details: This prospective cross-sectional study included 150 infants aged 0-3 years with AD and 80 control infants of similar age without chronic disease, acute or chronic infection, history of prematurity, developmental delay, neurometabolic disease, or atopy.
Disclosures: This study did not receive any funding. The authors declared no conflicts of interest.
Source: Koksal ZG and Uysal P. Beyond the skin: Reduced lung function associated with atopic dermatitis in infants. J Allergy Clin Immunol Pract. 2023 (Jul 3). Doi: 10.1016/j.jaip.2023.06.055
Baricitinib improves outcomes in moderate-to-severe atopic dermatitis
Key clinical point: In patients with moderate-to-severe atopic dermatitis (AD), baricitinib with or without topical corticosteroids (TCS) resulted in rapid achievement of the recommended absolute Eczema Area and Severity Index (EASI) and SCORing of AD (SCORAD) outcomes, which were sustained until week 16.
Major finding: An EASI score of ≤7 and a SCORAD score of <25 were achieved by significantly more patients receiving baricitinib (2 or 4 mg) vs placebo at all timepoints from week 1 (all P ≤ .01 and all P ≤ .05, respectively) and those receiving 4 mg baricitinib + TCS vs placebo + TCS at all timepoints from week 2 (all P ≤ .05 for both).
Study details: This post hoc analysis included 1316 patients with moderate-to-severe AD who received baricitinib (2 or 4 mg) or placebo in BREEZE-AD1/AD2 or baricitinib (2 or 4 mg)+TCS or placebo+TCS in BREEZE-AD7 for 16 weeks.
Disclosures: This study was funded by Eli Lilly and Company. Some authors reported ties with various organizations, including Eli Lilly. Three authors declared being current or former employees or shareholders of Eli Lilly.
Source: Thyssen JP et al. Baricitinib provides rapid and sustained improvements in absolute EASI and SCORAD outcomes in adults with moderate-to-severe atopic dermatitis. J Dermatolog Treat. 2023;34(1):2216322 (Jun 21). Doi: 10.1080/09546634.2023.2216322
Key clinical point: In patients with moderate-to-severe atopic dermatitis (AD), baricitinib with or without topical corticosteroids (TCS) resulted in rapid achievement of the recommended absolute Eczema Area and Severity Index (EASI) and SCORing of AD (SCORAD) outcomes, which were sustained until week 16.
Major finding: An EASI score of ≤7 and a SCORAD score of <25 were achieved by significantly more patients receiving baricitinib (2 or 4 mg) vs placebo at all timepoints from week 1 (all P ≤ .01 and all P ≤ .05, respectively) and those receiving 4 mg baricitinib + TCS vs placebo + TCS at all timepoints from week 2 (all P ≤ .05 for both).
Study details: This post hoc analysis included 1316 patients with moderate-to-severe AD who received baricitinib (2 or 4 mg) or placebo in BREEZE-AD1/AD2 or baricitinib (2 or 4 mg)+TCS or placebo+TCS in BREEZE-AD7 for 16 weeks.
Disclosures: This study was funded by Eli Lilly and Company. Some authors reported ties with various organizations, including Eli Lilly. Three authors declared being current or former employees or shareholders of Eli Lilly.
Source: Thyssen JP et al. Baricitinib provides rapid and sustained improvements in absolute EASI and SCORAD outcomes in adults with moderate-to-severe atopic dermatitis. J Dermatolog Treat. 2023;34(1):2216322 (Jun 21). Doi: 10.1080/09546634.2023.2216322
Key clinical point: In patients with moderate-to-severe atopic dermatitis (AD), baricitinib with or without topical corticosteroids (TCS) resulted in rapid achievement of the recommended absolute Eczema Area and Severity Index (EASI) and SCORing of AD (SCORAD) outcomes, which were sustained until week 16.
Major finding: An EASI score of ≤7 and a SCORAD score of <25 were achieved by significantly more patients receiving baricitinib (2 or 4 mg) vs placebo at all timepoints from week 1 (all P ≤ .01 and all P ≤ .05, respectively) and those receiving 4 mg baricitinib + TCS vs placebo + TCS at all timepoints from week 2 (all P ≤ .05 for both).
Study details: This post hoc analysis included 1316 patients with moderate-to-severe AD who received baricitinib (2 or 4 mg) or placebo in BREEZE-AD1/AD2 or baricitinib (2 or 4 mg)+TCS or placebo+TCS in BREEZE-AD7 for 16 weeks.
Disclosures: This study was funded by Eli Lilly and Company. Some authors reported ties with various organizations, including Eli Lilly. Three authors declared being current or former employees or shareholders of Eli Lilly.
Source: Thyssen JP et al. Baricitinib provides rapid and sustained improvements in absolute EASI and SCORAD outcomes in adults with moderate-to-severe atopic dermatitis. J Dermatolog Treat. 2023;34(1):2216322 (Jun 21). Doi: 10.1080/09546634.2023.2216322
Upadacitinib offers long-term benefits against treatment-resistant moderate-to-severe atopic dermatitis
Key clinical point: Upadacitinib demonstrated an acceptable safety profile and led to significant and sustained improvements in disease signs and symptoms through 48 weeks of observation in patients with moderate-to-severe atopic dermatitis (AD) who were unresponsive to conventional treatments.
Major finding: At weeks 16 and 48, an Eczema Area and Severity Index-75 response was achieved by 78.2% and 87.6% of patients, respectively, with a significant reduction in mean sleeplessness, skin pain, and itch Numeric Rating Scale scores (all P < .001). Most adverse events were of mild-to-moderate severity.
Study details: This real-world prospective study included 146 adult patients with moderate-to-severe AD who were unresponsive, intolerant, or had contraindications to the approved therapies for moderate-to-severe AD and received 15 or 30 mg upadacitinib alone or combined with corticosteroids for 48 weeks.
Disclosures: This study did not receive any funding. Some authors, including the lead author, declared serving as investigators, speakers, advisory board members, or consultants for or receiving lecture or speaker honoraria, research grants, or personal fees from various sources.
Source: Chiricozzi A et al. Long-term effectiveness and safety of upadacitinib for atopic dermatitis in a real-world setting: An interim analysis through 48 weeks of observation. Am J Clin Dermatol. 2023 (Jun 15). Doi: 10.1007/s40257-023-00798-0
Key clinical point: Upadacitinib demonstrated an acceptable safety profile and led to significant and sustained improvements in disease signs and symptoms through 48 weeks of observation in patients with moderate-to-severe atopic dermatitis (AD) who were unresponsive to conventional treatments.
Major finding: At weeks 16 and 48, an Eczema Area and Severity Index-75 response was achieved by 78.2% and 87.6% of patients, respectively, with a significant reduction in mean sleeplessness, skin pain, and itch Numeric Rating Scale scores (all P < .001). Most adverse events were of mild-to-moderate severity.
Study details: This real-world prospective study included 146 adult patients with moderate-to-severe AD who were unresponsive, intolerant, or had contraindications to the approved therapies for moderate-to-severe AD and received 15 or 30 mg upadacitinib alone or combined with corticosteroids for 48 weeks.
Disclosures: This study did not receive any funding. Some authors, including the lead author, declared serving as investigators, speakers, advisory board members, or consultants for or receiving lecture or speaker honoraria, research grants, or personal fees from various sources.
Source: Chiricozzi A et al. Long-term effectiveness and safety of upadacitinib for atopic dermatitis in a real-world setting: An interim analysis through 48 weeks of observation. Am J Clin Dermatol. 2023 (Jun 15). Doi: 10.1007/s40257-023-00798-0
Key clinical point: Upadacitinib demonstrated an acceptable safety profile and led to significant and sustained improvements in disease signs and symptoms through 48 weeks of observation in patients with moderate-to-severe atopic dermatitis (AD) who were unresponsive to conventional treatments.
Major finding: At weeks 16 and 48, an Eczema Area and Severity Index-75 response was achieved by 78.2% and 87.6% of patients, respectively, with a significant reduction in mean sleeplessness, skin pain, and itch Numeric Rating Scale scores (all P < .001). Most adverse events were of mild-to-moderate severity.
Study details: This real-world prospective study included 146 adult patients with moderate-to-severe AD who were unresponsive, intolerant, or had contraindications to the approved therapies for moderate-to-severe AD and received 15 or 30 mg upadacitinib alone or combined with corticosteroids for 48 weeks.
Disclosures: This study did not receive any funding. Some authors, including the lead author, declared serving as investigators, speakers, advisory board members, or consultants for or receiving lecture or speaker honoraria, research grants, or personal fees from various sources.
Source: Chiricozzi A et al. Long-term effectiveness and safety of upadacitinib for atopic dermatitis in a real-world setting: An interim analysis through 48 weeks of observation. Am J Clin Dermatol. 2023 (Jun 15). Doi: 10.1007/s40257-023-00798-0
Dupilumab rapidly reduces Staphylococcus aureus abundance in moderate-to-severe atopic dermatitis
Key clinical point: Dupilumab rapidly reduced the skin abundance of Staphylococcus aureus in patients with moderate-to-severe atopic dermatitis (AD), and the reduction correlated with improvements in all AD severity measurements except itch.
Major finding: At day 3, the dupilumab vs placebo group showed a 7.5-fold reduction (P = .02) in the skin abundance of S. aureus. A significant positive correlation was observed between the reduction in abundance and SCORing Atopic Dermatitis score with dupilumab (repeated measure correlation coefficient 0.39; P < .001), which was similar for other AD severity measurements except pruritus Numeric Rating Scale score.
Study details: Findings are from the multicenter, double-blind ADRN09 trial including 71 adult patients with moderate-to-severe AD who were randomly assigned to receive dupilumab (n = 45) or placebo (n = 26).
Disclosures: This study was supported by the US National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, Colorado. Some authors declared serving as consultants or investigators for and receiving research grants from various organizations.
Source: Simpson EL et al. Rapid reduction in Staphylococcus aureus in atopic dermatitis subjects following dupilumab treatment. J Allergy Clin Immunol. 2023 (Jun 12). Doi: 10.1016/j.jaci.2023.05.026
Key clinical point: Dupilumab rapidly reduced the skin abundance of Staphylococcus aureus in patients with moderate-to-severe atopic dermatitis (AD), and the reduction correlated with improvements in all AD severity measurements except itch.
Major finding: At day 3, the dupilumab vs placebo group showed a 7.5-fold reduction (P = .02) in the skin abundance of S. aureus. A significant positive correlation was observed between the reduction in abundance and SCORing Atopic Dermatitis score with dupilumab (repeated measure correlation coefficient 0.39; P < .001), which was similar for other AD severity measurements except pruritus Numeric Rating Scale score.
Study details: Findings are from the multicenter, double-blind ADRN09 trial including 71 adult patients with moderate-to-severe AD who were randomly assigned to receive dupilumab (n = 45) or placebo (n = 26).
Disclosures: This study was supported by the US National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, Colorado. Some authors declared serving as consultants or investigators for and receiving research grants from various organizations.
Source: Simpson EL et al. Rapid reduction in Staphylococcus aureus in atopic dermatitis subjects following dupilumab treatment. J Allergy Clin Immunol. 2023 (Jun 12). Doi: 10.1016/j.jaci.2023.05.026
Key clinical point: Dupilumab rapidly reduced the skin abundance of Staphylococcus aureus in patients with moderate-to-severe atopic dermatitis (AD), and the reduction correlated with improvements in all AD severity measurements except itch.
Major finding: At day 3, the dupilumab vs placebo group showed a 7.5-fold reduction (P = .02) in the skin abundance of S. aureus. A significant positive correlation was observed between the reduction in abundance and SCORing Atopic Dermatitis score with dupilumab (repeated measure correlation coefficient 0.39; P < .001), which was similar for other AD severity measurements except pruritus Numeric Rating Scale score.
Study details: Findings are from the multicenter, double-blind ADRN09 trial including 71 adult patients with moderate-to-severe AD who were randomly assigned to receive dupilumab (n = 45) or placebo (n = 26).
Disclosures: This study was supported by the US National Institute of Allergy and Infectious Diseases and the National Center for Advancing Translational Sciences, Colorado. Some authors declared serving as consultants or investigators for and receiving research grants from various organizations.
Source: Simpson EL et al. Rapid reduction in Staphylococcus aureus in atopic dermatitis subjects following dupilumab treatment. J Allergy Clin Immunol. 2023 (Jun 12). Doi: 10.1016/j.jaci.2023.05.026
Atopic dermatitis not associated with malignancy overall but increases the risk for lymphoma
Key clinical point: Atopic dermatitis (AD) is not associated with an overall increased risk for malignancy in children and adults; however, the risk for lymphoma is significantly higher in both children and adults with severe AD.
Major finding: The risk for overall malignancy was similar between the AD and non-AD groups of children (adjusted hazard ratio [aHR] 1.02; 95% CI 0.92-1.12) and adults (aHR 1.00; 95% CI 0.99-1.02); however, the risk for lymphoma (non-cutaneous T-cell type) was significantly higher in children (aHR 3.18; 95% CI 1.41-7.16) and adults (aHR 1.95; 95% CI 1.62-2.36) with severe AD.
Study details: This population-based cohort study included matched children (<18 years) with (n = 409,431) and without (n = 1,809,029) AD and matched adults with (n = 625,083) and without (n = 2,678,888) AD.
Disclosures: This study was funded by Pfizer, Inc. Some authors declared receiving research grants, consulting fees, or honoraria from Pfizer, Inc., and others. AR Lemeshow declared being an employee of Pfizer, Inc.
Source: Wan J et al. Malignancy risk in patients with atopic dermatitis: A population-based cohort study. Br J Dermatol. 2023;189(1):53-61 (Jul 7). Doi: 10.1093/bjd/ljad072
Key clinical point: Atopic dermatitis (AD) is not associated with an overall increased risk for malignancy in children and adults; however, the risk for lymphoma is significantly higher in both children and adults with severe AD.
Major finding: The risk for overall malignancy was similar between the AD and non-AD groups of children (adjusted hazard ratio [aHR] 1.02; 95% CI 0.92-1.12) and adults (aHR 1.00; 95% CI 0.99-1.02); however, the risk for lymphoma (non-cutaneous T-cell type) was significantly higher in children (aHR 3.18; 95% CI 1.41-7.16) and adults (aHR 1.95; 95% CI 1.62-2.36) with severe AD.
Study details: This population-based cohort study included matched children (<18 years) with (n = 409,431) and without (n = 1,809,029) AD and matched adults with (n = 625,083) and without (n = 2,678,888) AD.
Disclosures: This study was funded by Pfizer, Inc. Some authors declared receiving research grants, consulting fees, or honoraria from Pfizer, Inc., and others. AR Lemeshow declared being an employee of Pfizer, Inc.
Source: Wan J et al. Malignancy risk in patients with atopic dermatitis: A population-based cohort study. Br J Dermatol. 2023;189(1):53-61 (Jul 7). Doi: 10.1093/bjd/ljad072
Key clinical point: Atopic dermatitis (AD) is not associated with an overall increased risk for malignancy in children and adults; however, the risk for lymphoma is significantly higher in both children and adults with severe AD.
Major finding: The risk for overall malignancy was similar between the AD and non-AD groups of children (adjusted hazard ratio [aHR] 1.02; 95% CI 0.92-1.12) and adults (aHR 1.00; 95% CI 0.99-1.02); however, the risk for lymphoma (non-cutaneous T-cell type) was significantly higher in children (aHR 3.18; 95% CI 1.41-7.16) and adults (aHR 1.95; 95% CI 1.62-2.36) with severe AD.
Study details: This population-based cohort study included matched children (<18 years) with (n = 409,431) and without (n = 1,809,029) AD and matched adults with (n = 625,083) and without (n = 2,678,888) AD.
Disclosures: This study was funded by Pfizer, Inc. Some authors declared receiving research grants, consulting fees, or honoraria from Pfizer, Inc., and others. AR Lemeshow declared being an employee of Pfizer, Inc.
Source: Wan J et al. Malignancy risk in patients with atopic dermatitis: A population-based cohort study. Br J Dermatol. 2023;189(1):53-61 (Jul 7). Doi: 10.1093/bjd/ljad072
Lebrikizumab shows favorable benefit-risk profile in adolescents with moderate-to-severe atopic dermatitis
Key clinical point: Lebrikizumab demonstrated long-term efficacy and a safety profile consistent with that observed in previous trials in adolescents with moderate-to-severe atopic dermatitis (AD).
Major finding: At week 52, 62.6% and 81.9% of patients achieved an Investigator’s Global Assessment score of 0 or 1 with a ≥2-point reduction from baseline and an Eczema Area and Severity Index-75 response, respectively. Adverse events were mostly mild or moderate in severity and led to treatment discontinuation in 2.4% of patients.
Study details: This open-label phase 3 trial, ADore, included 206 adolescents (age ≥12 to <18 years) with moderate-to-severe AD who received lebrikizumab subcutaneously (500-mg loading dose at baseline and week 2, followed by 250 mg every 2 weeks).
Disclosures: This study was funded by Dermira, Inc., a wholly owned subsidiary of Eli Lilly and Company. Some authors declared receiving research grants or consulting, advisory board, or speaker honoraria from or serving as consultants, speakers, or investigators for Eli Lilly and others. Six authors declared being former or current employees or shareholders of Eli Lilly.
Source: Paller AS et al. Safety and efficacy of lebrikizumab in adolescent patients with moderate-to-severe atopic dermatitis: A 52-week, open-label, phase 3 study. Dermatol Ther (Heidelb). 2023;13(7):1517-1534 (Jun 15). Doi: 10.1007/s13555-023-00942-y
Key clinical point: Lebrikizumab demonstrated long-term efficacy and a safety profile consistent with that observed in previous trials in adolescents with moderate-to-severe atopic dermatitis (AD).
Major finding: At week 52, 62.6% and 81.9% of patients achieved an Investigator’s Global Assessment score of 0 or 1 with a ≥2-point reduction from baseline and an Eczema Area and Severity Index-75 response, respectively. Adverse events were mostly mild or moderate in severity and led to treatment discontinuation in 2.4% of patients.
Study details: This open-label phase 3 trial, ADore, included 206 adolescents (age ≥12 to <18 years) with moderate-to-severe AD who received lebrikizumab subcutaneously (500-mg loading dose at baseline and week 2, followed by 250 mg every 2 weeks).
Disclosures: This study was funded by Dermira, Inc., a wholly owned subsidiary of Eli Lilly and Company. Some authors declared receiving research grants or consulting, advisory board, or speaker honoraria from or serving as consultants, speakers, or investigators for Eli Lilly and others. Six authors declared being former or current employees or shareholders of Eli Lilly.
Source: Paller AS et al. Safety and efficacy of lebrikizumab in adolescent patients with moderate-to-severe atopic dermatitis: A 52-week, open-label, phase 3 study. Dermatol Ther (Heidelb). 2023;13(7):1517-1534 (Jun 15). Doi: 10.1007/s13555-023-00942-y
Key clinical point: Lebrikizumab demonstrated long-term efficacy and a safety profile consistent with that observed in previous trials in adolescents with moderate-to-severe atopic dermatitis (AD).
Major finding: At week 52, 62.6% and 81.9% of patients achieved an Investigator’s Global Assessment score of 0 or 1 with a ≥2-point reduction from baseline and an Eczema Area and Severity Index-75 response, respectively. Adverse events were mostly mild or moderate in severity and led to treatment discontinuation in 2.4% of patients.
Study details: This open-label phase 3 trial, ADore, included 206 adolescents (age ≥12 to <18 years) with moderate-to-severe AD who received lebrikizumab subcutaneously (500-mg loading dose at baseline and week 2, followed by 250 mg every 2 weeks).
Disclosures: This study was funded by Dermira, Inc., a wholly owned subsidiary of Eli Lilly and Company. Some authors declared receiving research grants or consulting, advisory board, or speaker honoraria from or serving as consultants, speakers, or investigators for Eli Lilly and others. Six authors declared being former or current employees or shareholders of Eli Lilly.
Source: Paller AS et al. Safety and efficacy of lebrikizumab in adolescent patients with moderate-to-severe atopic dermatitis: A 52-week, open-label, phase 3 study. Dermatol Ther (Heidelb). 2023;13(7):1517-1534 (Jun 15). Doi: 10.1007/s13555-023-00942-y
Phase 3 trial supports long-term efficacy and safety of abrocitinib in moderate-to-severe atopic dermatitis
Key clinical point: Long-term abrocitinib monotherapy or with medicated topical therapy demonstrates a manageable safety profile and significantly improves the signs and symptoms of moderate-to-severe atopic dermatitis (AD) in adults and adolescents.
Major finding: At week 48, in the 200 and 100 mg abrocitinib groups, Eczema Area and Severity Index-75 (EASI 75) responses and ≥4-point improvements in Peak Pruritus Numerical Rating Scale (PP-NRS) scores were achieved by 81.7% and 66.8% (EASI 75), and 67.9% and 51.1% (PP-NRS) of patients, respectively; serious treatment-emergent adverse event rates were 7.1% and 4.7% (200 mg vs 100 mg), respectively.
Study details: This phase 3 long-term extension study JADE EXTEND (n = 1116) included patients (≥12 years) with moderate-to-severe AD who completed abrocitinib (200/100 mg) or placebo treatment in JADE MONO-1, JADE MONO-2, or JADE COMPARE study and received abrocitinib (200/100 mg) with or without topical therapy.
Disclosures: This study was funded by Pfizer Inc. Some authors declared receiving grants, fees, etc., from and serving as consultants, speakers, advisors, or investigators for Pfizer Inc. and others. Five authors declared being employees or shareholders of Pfizer Inc.
Source: Reich K et al. Abrocitinib efficacy and safety in patients with moderate-to-severe atopic dermatitis: Results from phase 3 studies, including the long-term extension JADE EXTEND study. J Eur Acad Dermatol Venereol. 2023 (Jun 19). Doi: 10.1111/jdv.19280
Key clinical point: Long-term abrocitinib monotherapy or with medicated topical therapy demonstrates a manageable safety profile and significantly improves the signs and symptoms of moderate-to-severe atopic dermatitis (AD) in adults and adolescents.
Major finding: At week 48, in the 200 and 100 mg abrocitinib groups, Eczema Area and Severity Index-75 (EASI 75) responses and ≥4-point improvements in Peak Pruritus Numerical Rating Scale (PP-NRS) scores were achieved by 81.7% and 66.8% (EASI 75), and 67.9% and 51.1% (PP-NRS) of patients, respectively; serious treatment-emergent adverse event rates were 7.1% and 4.7% (200 mg vs 100 mg), respectively.
Study details: This phase 3 long-term extension study JADE EXTEND (n = 1116) included patients (≥12 years) with moderate-to-severe AD who completed abrocitinib (200/100 mg) or placebo treatment in JADE MONO-1, JADE MONO-2, or JADE COMPARE study and received abrocitinib (200/100 mg) with or without topical therapy.
Disclosures: This study was funded by Pfizer Inc. Some authors declared receiving grants, fees, etc., from and serving as consultants, speakers, advisors, or investigators for Pfizer Inc. and others. Five authors declared being employees or shareholders of Pfizer Inc.
Source: Reich K et al. Abrocitinib efficacy and safety in patients with moderate-to-severe atopic dermatitis: Results from phase 3 studies, including the long-term extension JADE EXTEND study. J Eur Acad Dermatol Venereol. 2023 (Jun 19). Doi: 10.1111/jdv.19280
Key clinical point: Long-term abrocitinib monotherapy or with medicated topical therapy demonstrates a manageable safety profile and significantly improves the signs and symptoms of moderate-to-severe atopic dermatitis (AD) in adults and adolescents.
Major finding: At week 48, in the 200 and 100 mg abrocitinib groups, Eczema Area and Severity Index-75 (EASI 75) responses and ≥4-point improvements in Peak Pruritus Numerical Rating Scale (PP-NRS) scores were achieved by 81.7% and 66.8% (EASI 75), and 67.9% and 51.1% (PP-NRS) of patients, respectively; serious treatment-emergent adverse event rates were 7.1% and 4.7% (200 mg vs 100 mg), respectively.
Study details: This phase 3 long-term extension study JADE EXTEND (n = 1116) included patients (≥12 years) with moderate-to-severe AD who completed abrocitinib (200/100 mg) or placebo treatment in JADE MONO-1, JADE MONO-2, or JADE COMPARE study and received abrocitinib (200/100 mg) with or without topical therapy.
Disclosures: This study was funded by Pfizer Inc. Some authors declared receiving grants, fees, etc., from and serving as consultants, speakers, advisors, or investigators for Pfizer Inc. and others. Five authors declared being employees or shareholders of Pfizer Inc.
Source: Reich K et al. Abrocitinib efficacy and safety in patients with moderate-to-severe atopic dermatitis: Results from phase 3 studies, including the long-term extension JADE EXTEND study. J Eur Acad Dermatol Venereol. 2023 (Jun 19). Doi: 10.1111/jdv.19280
When treating AD in children, experts consider adherence, other aspects of treatment
ASHEVILLE, N.C. – according to a three-member expert panel mulling over strategies at the annual meeting of the Society for Pediatric Dermatology.
In introductory remarks, the three panelists briefly addressed different aspects for controlling AD, including drugs in the pipeline, the potential value of alternative therapies, and whom to blame when compliance is poor.
But panel discussion following these presentations provided an opportunity for audience engagement on practical strategies for improving AD control.
In her formal remarks prior to the panel discussion, Amy S. Paller, MD, professor of dermatology and pediatrics and chair of dermatology, Northwestern University, Chicago, and a pediatric dermatologist at the Lurie Children’s Hospital of Chicago, described emerging AD treatments. This included an update on the status of the interleukin-13 (IL-13) inhibitors tralokinumab (Adbry), which was approved by the FDA for treating AD in adults in December 2021, and lebrikizumab, which is thought likely to be soon approved in the United States on the basis of two recently published phase 3 trials.
Along with dupilumab (Dupixent) for moderate-to-severe AD in children who do not respond to optimized use of topical therapies, these new biologics appear likely to further expand choices for AD control for adults (and for kids with AD too, if eventually licensed in children), according to the data from the phase 3 studies.
During a panel discussion that followed, Stephen Gellis, MD, pediatric dermatologist and former chief of pediatric dermatology at Boston Children’s Hospital and Harvard Medical School, raised the point of optimizing tried and true topical therapies before using systemic agents. He noted that parents sometimes pressure clinicians to use a biologic – and that moving too quickly to the latest and most expensive drugs may not be necessary.
Dr. Paller acknowledged that she, like many pediatric dermatologists, employed immunosuppressants as her drugs of choice for many years – commonly starting with a few months of cyclosporine before transitioning to methotrexate, which has a delayed onset of action. In fact, she still uses this regimen in some children.
However, she now prefers dupilumab, which is the first biologic available for children in the United States with an AD indication in children as young as 6 months. She said dupilumab has fewer potential risks than cyclosporine, and it offers clinically meaningful improvement in most children. She noted that current guidelines discourage the use of systemic corticosteroids for AD in children, given their potential toxicity.
She strongly agreed with Dr. Gellis that clinicians should resist pressure to use any systemic agent if children are responding well to topical medications. In her own practice, Dr. Paller moves to systemic medications only after ensuring that there has been adherence to appropriate therapy and that there is not another diagnosis that might explain the recalcitrance to topical agents.
When a systemic medication is considered the next step, Dr. Paller reminded the audience of the importance of presenting the benefits and risks of all the options for AD control, which could include dupilumab and immunosuppressants as initial systemic therapy.
“Many parents choose biologic treatment first, given its lack of requirement for blood monitoring and faster action than methotrexate,” Dr. Paller noted.
Nevertheless, “biologics are much more costly than immunosuppressants, require an injection – which is stressful for the child and the parents – and may not be accessible for our patients,” Dr. Paller said. Cyclosporine and methotrexate are effective and are often the best options for moderate to severe disease in areas of the world where dupilumab is not available, but Dr. Paller most commonly uses these therapies only when reimbursement for dupilumab cannot be secured, injection is not an option, or when dupilumab is not sufficiently effective and tolerated.
Providing different perspectives, the two other panelists discussing the treatment of pediatric AD also saw a role for ensuring that topical agents are not offering adequate AD control before turning to the latest and most sophisticated therapies for AD.
For meeting parent expectations when children are improving slowly on topical therapies, Peter A. Lio, MD, director of the Chicago Integrative Eczema Center and clinical assistant professor of dermatology and pediatrics at Northwestern University, suggested that integrative medicine might be helpful.
For parents not fully comfortable with standard pharmacologic agents, Dr. Lio said there is evidence to support some of the complementary approaches, and these can be reassuring to parents with an interest in alternative medicines.
In Western medicine, it is common to hear terms like “attack,” “kill,” and “suppress,” disease, but alternative therapies are generally coupled with terms like “restore,” “strengthen,” and “tonify,” he said. “Who doesn’t want to be tonified?” he asked, noting that there are many sources of data suggesting that the number of patients seeking alternative medicine is “huge.” The alternative medicines are not generally taught in medical school and remain widely ignored in typical practice, but “our patients are interested even if we are not.”
Yet, there are data to support benefit from some of these alternative therapies, providing a win-win situation for patients who derive satisfaction from nontraditional therapies alone or combined with established pharmaceutical treatments.
Of these, Dr. Lio said there is support for the use of hempseed oil as a moisturizing agent and a strategy for improving barrier function in the skin of patients with AD. In a controlled crossover study, 2 teaspoons per day of dietary hempseed oil, a product that can be purchased in some grocery stores, was associated with significant reductions in skin dryness, itchiness, and use of topical medications relative to the same amount of olive oil, he noted.
Other examples include a compress made with black tea that was associated with an anti-inflammatory effect when followed by a moisturizer, a published study asserts. Although this was a trial in adults with facial dermatitis, Dr. Lio suggested that the same anti-inflammatory effect would be anticipated for other skin conditions, including AD in children.
As a third example, Dr. Lio said topical indigo, a traditional Chinese medicine used for a variety of dermatologic conditions, including psoriasis, has also demonstrated efficacy in a randomized trial, compared with vehicle for mild to severe AD.
Complementary medicines are not for everyone, but they may have a role when managing the expectations of parents who are not fully satisfied or express concern about regimens limited to mainstream therapies alone, according to Dr. Lio. In diseases that are not curable, such as AD, he thinks this is a strategy with potential for benefit and is reassuring to patients.
Another way to avoid moving to riskier or more expensive drugs quickly is to assure patients use the drugs that were prescribed first, according to Steven R. Feldman, MD, PhD, professor of dermatology, Wake Forest University, Winston-Salem, N.C.
Dr. Feldman believes that failure to adhere to therapy is basically the fault of the medical care system, not the patient. He made an analogy to a successful piano teacher, who provides a child with sheet music and then sees the child once a week to track progress. He juxtaposed this piano teacher to one who gives the child sheet music and tells the child to come back in 10 weeks for the recital. It is not hard to guess which approach would be more effective.
“Typically, doctors are worse than that second teacher,” he said. “Doctors are like a piano teacher that does not give you the sheet music but says, ‘Here is a prescription for some sheet music. Take this prescription to the sheet music store. I have no idea how much it will cost or whether your insurance will pay for it. But once you fill this prescription for sheet music, I want you to practice this every day,’ ” he said, adding, “Practicing this sheet music may cause rashes, diarrhea, or serious infection. When the patient next comes in 10-12 weeks later and is not better, the doctor says, ‘I will give you a harder piece of sheet music and maybe two or three other instruments to practice at the same time,’ ” said Dr. Feldman, expressing why the way clinicians practice might explain much of the poor adherence problem.
This largely explains why patients with AD do not immediately respond to the therapies doctors prescribe, Dr. Feldman implied, reiterating the theme that emerged from the AD panel: Better and more options are needed for AD of the most severe types, but better management, not better drugs, is typically what is needed for most patients.
Dr. Feldman, Dr. Lio, and Dr. Paller have financial relationships with more than 30 pharmaceutical and cosmetic companies, some of which manufacture therapies for atopic dermatitis.
This article was updated July 28, 2023, to clarify the comments and viewpoints of Dr. Amy Paller.
A version of this article first appeared on Medscape.com.
ASHEVILLE, N.C. – according to a three-member expert panel mulling over strategies at the annual meeting of the Society for Pediatric Dermatology.
In introductory remarks, the three panelists briefly addressed different aspects for controlling AD, including drugs in the pipeline, the potential value of alternative therapies, and whom to blame when compliance is poor.
But panel discussion following these presentations provided an opportunity for audience engagement on practical strategies for improving AD control.
In her formal remarks prior to the panel discussion, Amy S. Paller, MD, professor of dermatology and pediatrics and chair of dermatology, Northwestern University, Chicago, and a pediatric dermatologist at the Lurie Children’s Hospital of Chicago, described emerging AD treatments. This included an update on the status of the interleukin-13 (IL-13) inhibitors tralokinumab (Adbry), which was approved by the FDA for treating AD in adults in December 2021, and lebrikizumab, which is thought likely to be soon approved in the United States on the basis of two recently published phase 3 trials.
Along with dupilumab (Dupixent) for moderate-to-severe AD in children who do not respond to optimized use of topical therapies, these new biologics appear likely to further expand choices for AD control for adults (and for kids with AD too, if eventually licensed in children), according to the data from the phase 3 studies.
During a panel discussion that followed, Stephen Gellis, MD, pediatric dermatologist and former chief of pediatric dermatology at Boston Children’s Hospital and Harvard Medical School, raised the point of optimizing tried and true topical therapies before using systemic agents. He noted that parents sometimes pressure clinicians to use a biologic – and that moving too quickly to the latest and most expensive drugs may not be necessary.
Dr. Paller acknowledged that she, like many pediatric dermatologists, employed immunosuppressants as her drugs of choice for many years – commonly starting with a few months of cyclosporine before transitioning to methotrexate, which has a delayed onset of action. In fact, she still uses this regimen in some children.
However, she now prefers dupilumab, which is the first biologic available for children in the United States with an AD indication in children as young as 6 months. She said dupilumab has fewer potential risks than cyclosporine, and it offers clinically meaningful improvement in most children. She noted that current guidelines discourage the use of systemic corticosteroids for AD in children, given their potential toxicity.
She strongly agreed with Dr. Gellis that clinicians should resist pressure to use any systemic agent if children are responding well to topical medications. In her own practice, Dr. Paller moves to systemic medications only after ensuring that there has been adherence to appropriate therapy and that there is not another diagnosis that might explain the recalcitrance to topical agents.
When a systemic medication is considered the next step, Dr. Paller reminded the audience of the importance of presenting the benefits and risks of all the options for AD control, which could include dupilumab and immunosuppressants as initial systemic therapy.
“Many parents choose biologic treatment first, given its lack of requirement for blood monitoring and faster action than methotrexate,” Dr. Paller noted.
Nevertheless, “biologics are much more costly than immunosuppressants, require an injection – which is stressful for the child and the parents – and may not be accessible for our patients,” Dr. Paller said. Cyclosporine and methotrexate are effective and are often the best options for moderate to severe disease in areas of the world where dupilumab is not available, but Dr. Paller most commonly uses these therapies only when reimbursement for dupilumab cannot be secured, injection is not an option, or when dupilumab is not sufficiently effective and tolerated.
Providing different perspectives, the two other panelists discussing the treatment of pediatric AD also saw a role for ensuring that topical agents are not offering adequate AD control before turning to the latest and most sophisticated therapies for AD.
For meeting parent expectations when children are improving slowly on topical therapies, Peter A. Lio, MD, director of the Chicago Integrative Eczema Center and clinical assistant professor of dermatology and pediatrics at Northwestern University, suggested that integrative medicine might be helpful.
For parents not fully comfortable with standard pharmacologic agents, Dr. Lio said there is evidence to support some of the complementary approaches, and these can be reassuring to parents with an interest in alternative medicines.
In Western medicine, it is common to hear terms like “attack,” “kill,” and “suppress,” disease, but alternative therapies are generally coupled with terms like “restore,” “strengthen,” and “tonify,” he said. “Who doesn’t want to be tonified?” he asked, noting that there are many sources of data suggesting that the number of patients seeking alternative medicine is “huge.” The alternative medicines are not generally taught in medical school and remain widely ignored in typical practice, but “our patients are interested even if we are not.”
Yet, there are data to support benefit from some of these alternative therapies, providing a win-win situation for patients who derive satisfaction from nontraditional therapies alone or combined with established pharmaceutical treatments.
Of these, Dr. Lio said there is support for the use of hempseed oil as a moisturizing agent and a strategy for improving barrier function in the skin of patients with AD. In a controlled crossover study, 2 teaspoons per day of dietary hempseed oil, a product that can be purchased in some grocery stores, was associated with significant reductions in skin dryness, itchiness, and use of topical medications relative to the same amount of olive oil, he noted.
Other examples include a compress made with black tea that was associated with an anti-inflammatory effect when followed by a moisturizer, a published study asserts. Although this was a trial in adults with facial dermatitis, Dr. Lio suggested that the same anti-inflammatory effect would be anticipated for other skin conditions, including AD in children.
As a third example, Dr. Lio said topical indigo, a traditional Chinese medicine used for a variety of dermatologic conditions, including psoriasis, has also demonstrated efficacy in a randomized trial, compared with vehicle for mild to severe AD.
Complementary medicines are not for everyone, but they may have a role when managing the expectations of parents who are not fully satisfied or express concern about regimens limited to mainstream therapies alone, according to Dr. Lio. In diseases that are not curable, such as AD, he thinks this is a strategy with potential for benefit and is reassuring to patients.
Another way to avoid moving to riskier or more expensive drugs quickly is to assure patients use the drugs that were prescribed first, according to Steven R. Feldman, MD, PhD, professor of dermatology, Wake Forest University, Winston-Salem, N.C.
Dr. Feldman believes that failure to adhere to therapy is basically the fault of the medical care system, not the patient. He made an analogy to a successful piano teacher, who provides a child with sheet music and then sees the child once a week to track progress. He juxtaposed this piano teacher to one who gives the child sheet music and tells the child to come back in 10 weeks for the recital. It is not hard to guess which approach would be more effective.
“Typically, doctors are worse than that second teacher,” he said. “Doctors are like a piano teacher that does not give you the sheet music but says, ‘Here is a prescription for some sheet music. Take this prescription to the sheet music store. I have no idea how much it will cost or whether your insurance will pay for it. But once you fill this prescription for sheet music, I want you to practice this every day,’ ” he said, adding, “Practicing this sheet music may cause rashes, diarrhea, or serious infection. When the patient next comes in 10-12 weeks later and is not better, the doctor says, ‘I will give you a harder piece of sheet music and maybe two or three other instruments to practice at the same time,’ ” said Dr. Feldman, expressing why the way clinicians practice might explain much of the poor adherence problem.
This largely explains why patients with AD do not immediately respond to the therapies doctors prescribe, Dr. Feldman implied, reiterating the theme that emerged from the AD panel: Better and more options are needed for AD of the most severe types, but better management, not better drugs, is typically what is needed for most patients.
Dr. Feldman, Dr. Lio, and Dr. Paller have financial relationships with more than 30 pharmaceutical and cosmetic companies, some of which manufacture therapies for atopic dermatitis.
This article was updated July 28, 2023, to clarify the comments and viewpoints of Dr. Amy Paller.
A version of this article first appeared on Medscape.com.
ASHEVILLE, N.C. – according to a three-member expert panel mulling over strategies at the annual meeting of the Society for Pediatric Dermatology.
In introductory remarks, the three panelists briefly addressed different aspects for controlling AD, including drugs in the pipeline, the potential value of alternative therapies, and whom to blame when compliance is poor.
But panel discussion following these presentations provided an opportunity for audience engagement on practical strategies for improving AD control.
In her formal remarks prior to the panel discussion, Amy S. Paller, MD, professor of dermatology and pediatrics and chair of dermatology, Northwestern University, Chicago, and a pediatric dermatologist at the Lurie Children’s Hospital of Chicago, described emerging AD treatments. This included an update on the status of the interleukin-13 (IL-13) inhibitors tralokinumab (Adbry), which was approved by the FDA for treating AD in adults in December 2021, and lebrikizumab, which is thought likely to be soon approved in the United States on the basis of two recently published phase 3 trials.
Along with dupilumab (Dupixent) for moderate-to-severe AD in children who do not respond to optimized use of topical therapies, these new biologics appear likely to further expand choices for AD control for adults (and for kids with AD too, if eventually licensed in children), according to the data from the phase 3 studies.
During a panel discussion that followed, Stephen Gellis, MD, pediatric dermatologist and former chief of pediatric dermatology at Boston Children’s Hospital and Harvard Medical School, raised the point of optimizing tried and true topical therapies before using systemic agents. He noted that parents sometimes pressure clinicians to use a biologic – and that moving too quickly to the latest and most expensive drugs may not be necessary.
Dr. Paller acknowledged that she, like many pediatric dermatologists, employed immunosuppressants as her drugs of choice for many years – commonly starting with a few months of cyclosporine before transitioning to methotrexate, which has a delayed onset of action. In fact, she still uses this regimen in some children.
However, she now prefers dupilumab, which is the first biologic available for children in the United States with an AD indication in children as young as 6 months. She said dupilumab has fewer potential risks than cyclosporine, and it offers clinically meaningful improvement in most children. She noted that current guidelines discourage the use of systemic corticosteroids for AD in children, given their potential toxicity.
She strongly agreed with Dr. Gellis that clinicians should resist pressure to use any systemic agent if children are responding well to topical medications. In her own practice, Dr. Paller moves to systemic medications only after ensuring that there has been adherence to appropriate therapy and that there is not another diagnosis that might explain the recalcitrance to topical agents.
When a systemic medication is considered the next step, Dr. Paller reminded the audience of the importance of presenting the benefits and risks of all the options for AD control, which could include dupilumab and immunosuppressants as initial systemic therapy.
“Many parents choose biologic treatment first, given its lack of requirement for blood monitoring and faster action than methotrexate,” Dr. Paller noted.
Nevertheless, “biologics are much more costly than immunosuppressants, require an injection – which is stressful for the child and the parents – and may not be accessible for our patients,” Dr. Paller said. Cyclosporine and methotrexate are effective and are often the best options for moderate to severe disease in areas of the world where dupilumab is not available, but Dr. Paller most commonly uses these therapies only when reimbursement for dupilumab cannot be secured, injection is not an option, or when dupilumab is not sufficiently effective and tolerated.
Providing different perspectives, the two other panelists discussing the treatment of pediatric AD also saw a role for ensuring that topical agents are not offering adequate AD control before turning to the latest and most sophisticated therapies for AD.
For meeting parent expectations when children are improving slowly on topical therapies, Peter A. Lio, MD, director of the Chicago Integrative Eczema Center and clinical assistant professor of dermatology and pediatrics at Northwestern University, suggested that integrative medicine might be helpful.
For parents not fully comfortable with standard pharmacologic agents, Dr. Lio said there is evidence to support some of the complementary approaches, and these can be reassuring to parents with an interest in alternative medicines.
In Western medicine, it is common to hear terms like “attack,” “kill,” and “suppress,” disease, but alternative therapies are generally coupled with terms like “restore,” “strengthen,” and “tonify,” he said. “Who doesn’t want to be tonified?” he asked, noting that there are many sources of data suggesting that the number of patients seeking alternative medicine is “huge.” The alternative medicines are not generally taught in medical school and remain widely ignored in typical practice, but “our patients are interested even if we are not.”
Yet, there are data to support benefit from some of these alternative therapies, providing a win-win situation for patients who derive satisfaction from nontraditional therapies alone or combined with established pharmaceutical treatments.
Of these, Dr. Lio said there is support for the use of hempseed oil as a moisturizing agent and a strategy for improving barrier function in the skin of patients with AD. In a controlled crossover study, 2 teaspoons per day of dietary hempseed oil, a product that can be purchased in some grocery stores, was associated with significant reductions in skin dryness, itchiness, and use of topical medications relative to the same amount of olive oil, he noted.
Other examples include a compress made with black tea that was associated with an anti-inflammatory effect when followed by a moisturizer, a published study asserts. Although this was a trial in adults with facial dermatitis, Dr. Lio suggested that the same anti-inflammatory effect would be anticipated for other skin conditions, including AD in children.
As a third example, Dr. Lio said topical indigo, a traditional Chinese medicine used for a variety of dermatologic conditions, including psoriasis, has also demonstrated efficacy in a randomized trial, compared with vehicle for mild to severe AD.
Complementary medicines are not for everyone, but they may have a role when managing the expectations of parents who are not fully satisfied or express concern about regimens limited to mainstream therapies alone, according to Dr. Lio. In diseases that are not curable, such as AD, he thinks this is a strategy with potential for benefit and is reassuring to patients.
Another way to avoid moving to riskier or more expensive drugs quickly is to assure patients use the drugs that were prescribed first, according to Steven R. Feldman, MD, PhD, professor of dermatology, Wake Forest University, Winston-Salem, N.C.
Dr. Feldman believes that failure to adhere to therapy is basically the fault of the medical care system, not the patient. He made an analogy to a successful piano teacher, who provides a child with sheet music and then sees the child once a week to track progress. He juxtaposed this piano teacher to one who gives the child sheet music and tells the child to come back in 10 weeks for the recital. It is not hard to guess which approach would be more effective.
“Typically, doctors are worse than that second teacher,” he said. “Doctors are like a piano teacher that does not give you the sheet music but says, ‘Here is a prescription for some sheet music. Take this prescription to the sheet music store. I have no idea how much it will cost or whether your insurance will pay for it. But once you fill this prescription for sheet music, I want you to practice this every day,’ ” he said, adding, “Practicing this sheet music may cause rashes, diarrhea, or serious infection. When the patient next comes in 10-12 weeks later and is not better, the doctor says, ‘I will give you a harder piece of sheet music and maybe two or three other instruments to practice at the same time,’ ” said Dr. Feldman, expressing why the way clinicians practice might explain much of the poor adherence problem.
This largely explains why patients with AD do not immediately respond to the therapies doctors prescribe, Dr. Feldman implied, reiterating the theme that emerged from the AD panel: Better and more options are needed for AD of the most severe types, but better management, not better drugs, is typically what is needed for most patients.
Dr. Feldman, Dr. Lio, and Dr. Paller have financial relationships with more than 30 pharmaceutical and cosmetic companies, some of which manufacture therapies for atopic dermatitis.
This article was updated July 28, 2023, to clarify the comments and viewpoints of Dr. Amy Paller.
A version of this article first appeared on Medscape.com.
AT SPD 2023
Ocular complications of dermatologic treatments: Advice from a pediatric ophthalmologist
ASHEVILLE, N.C. – The, according to one of several clinical messages from a pediatric ophthalmologist who spoke at the annual meeting of the Society for Pediatric Dermatology.
“There is a lot of steroid fear out there, which you can argue is actually harmful in itself, because not treating periorbital eczema is related to a lot of eye problems, including chronic discomfort and the eye rubbing that can cause corneal abrasions and keratoconus,” said Sara Grace, MD, a pediatric ophthalmologist who is on the clinical staff at Duke University, Durham, N.C. She maintains a practice at North Carolina Eye, Ear, Nose, and Throat in Durham.
Although the risks of periorbital steroid absorption are real, a limited course of low potency topical steroids is generally adequate for common periorbital indications, and these appear to be safe.
“There is insufficient evidence to link weak periocular topical corticosteroids such as desonide or hydrocortisone with ocular complications,” said Dr. Grace, suggesting that pediatric dermatologists can be reassured when using these medications at low concentrations.
“Potent periocular steroids have been associated with ocular complications, but this has typically involved exposures over months to years,” Dr. Grace specified.
When topical corticosteroids are applied at high concentrations on the face away from the periorbital area, glaucoma and other feared ophthalmic complications cannot be entirely ruled out, but, again, the risk is low in the absence of “very large quantities” of potent topical agents applied for lengthy periods of time, according to Dr. Grace, basing this observation on case studies.
In children, as in adults, the potential exception is a child with existing ocular disease. In such cases, or in children with risk factors for ocular disease, Dr. Grace recommends referral to an ophthalmologist for a baseline examination prior to a course of topical corticosteroids with the potential of periocular absorption. With a baseline assessment, adverse effects are more easily documented if exposure is prolonged.
The message, although not identical, is similar for use of dupilumab (Dupixent) or other biologics that target the interleukin-13 (IL-13) pathway. The potential for complications cannot be ignored but these are often time-limited and the benefit is likely to exceed the risk in children who have severe atopic dermatitis or other skin conditions for which these treatments are effective.
There are several potential mechanisms by which biologics targeting IL-13 might increase risk of ocular complications, one of which is the role that IL-13 plays in ocular mucus production, regulation of conjunctival goblet cells, and tear production, according to several published reports.
“Up to 30% of children will get some type of eye complication but, fortunately, most of them will not have to stop therapy,” Dr. Grace said. These side effects include conjunctivitis, blepharitis, keratitis, dry eye, and itching, but they are typically manageable. Topical steroids or calcineurin inhibitors can be offered if needed, but many of these conditions will self-resolve. Dr. Grace estimated that less than 1% of patients need to stop treatment because of ophthalmic side effects.
Lesions that obstruct vision
Dr. Grace urged pediatric dermatologists to be aware of the risk for amblyopia in young children with lesions that obstruct vision in one eye. In early development, prolonged obstruction of vision in one eye can alter neural communication with the brain, producing permanent vision impairment.
She explained that clearing the obstructed vision, whether from a capillary hemangioma or any periorbital growth, should be considered urgent to avoid irreversible damage.
Similarly, periorbital port-wine stains associated with Sturge-Weber syndrome, which is primarily a vascular disorder that predisposes children to glaucoma, represents a condition that requires prompt attention. Sturge-Weber syndrome is often but not always identified at birth, but it is a condition for which evaluation and treatment should involve the participation of an ophthalmologist.
Meibomian gland disease is another disorder that is often seen first by a pediatric dermatologist but also requires collaborative management. The challenge is sorting out the underlying cause or causes and initiating a therapy that unclogs the gland without having to resort to incision and drainage.
“Drainage is hard to do and is not necessarily effective,” explained Dr. Grace. While scrubs, warmth, and massage frequently are adequate to unclog the gland – which secretes meibum, a complex of lipids that perform several functions in protecting the eye – therapies specific to the cause, such as Demodex-related blepharitis, chalazions, and styes, might be needed.
Dr. Grace indicated that patience is often needed. The process of unclogging these glands often takes time, but she emphasized that a first-line conservative approach is always appropriate to avoid the difficulty and potential problems of incisions.
In general, these messages are not novel, but they provide a refresher for pediatric dermatologists who do not regularly confront complications that involve the eyes. According to session moderator, Elizabeth Neiman, MD, assistant professor of pediatric dermatology, University of North Carolina at Chapel Hill, the messages regarding topical steroids on the face and the eyes are “important” and worth emphasizing.
“It’s useful to reinforce the point that corticosteroids should be used when needed in the periorbital area [to control skin diseases] if they are used in low concentrations,” Dr. Neiman told this news organization.
Similarly, conjunctivitis and other ocular complications of dupilumab are a source of concern for parents as well as dermatologists. Dr. Neiman indicated that a review of the benefit-to-risk ratio is important when considering these treatments in patients with indications for severe skin disorders.
Dr. Grace and Dr. Nieman have no potential financial conflicts related to this topic.
A version of this article first appeared on Medscape.com.
ASHEVILLE, N.C. – The, according to one of several clinical messages from a pediatric ophthalmologist who spoke at the annual meeting of the Society for Pediatric Dermatology.
“There is a lot of steroid fear out there, which you can argue is actually harmful in itself, because not treating periorbital eczema is related to a lot of eye problems, including chronic discomfort and the eye rubbing that can cause corneal abrasions and keratoconus,” said Sara Grace, MD, a pediatric ophthalmologist who is on the clinical staff at Duke University, Durham, N.C. She maintains a practice at North Carolina Eye, Ear, Nose, and Throat in Durham.
Although the risks of periorbital steroid absorption are real, a limited course of low potency topical steroids is generally adequate for common periorbital indications, and these appear to be safe.
“There is insufficient evidence to link weak periocular topical corticosteroids such as desonide or hydrocortisone with ocular complications,” said Dr. Grace, suggesting that pediatric dermatologists can be reassured when using these medications at low concentrations.
“Potent periocular steroids have been associated with ocular complications, but this has typically involved exposures over months to years,” Dr. Grace specified.
When topical corticosteroids are applied at high concentrations on the face away from the periorbital area, glaucoma and other feared ophthalmic complications cannot be entirely ruled out, but, again, the risk is low in the absence of “very large quantities” of potent topical agents applied for lengthy periods of time, according to Dr. Grace, basing this observation on case studies.
In children, as in adults, the potential exception is a child with existing ocular disease. In such cases, or in children with risk factors for ocular disease, Dr. Grace recommends referral to an ophthalmologist for a baseline examination prior to a course of topical corticosteroids with the potential of periocular absorption. With a baseline assessment, adverse effects are more easily documented if exposure is prolonged.
The message, although not identical, is similar for use of dupilumab (Dupixent) or other biologics that target the interleukin-13 (IL-13) pathway. The potential for complications cannot be ignored but these are often time-limited and the benefit is likely to exceed the risk in children who have severe atopic dermatitis or other skin conditions for which these treatments are effective.
There are several potential mechanisms by which biologics targeting IL-13 might increase risk of ocular complications, one of which is the role that IL-13 plays in ocular mucus production, regulation of conjunctival goblet cells, and tear production, according to several published reports.
“Up to 30% of children will get some type of eye complication but, fortunately, most of them will not have to stop therapy,” Dr. Grace said. These side effects include conjunctivitis, blepharitis, keratitis, dry eye, and itching, but they are typically manageable. Topical steroids or calcineurin inhibitors can be offered if needed, but many of these conditions will self-resolve. Dr. Grace estimated that less than 1% of patients need to stop treatment because of ophthalmic side effects.
Lesions that obstruct vision
Dr. Grace urged pediatric dermatologists to be aware of the risk for amblyopia in young children with lesions that obstruct vision in one eye. In early development, prolonged obstruction of vision in one eye can alter neural communication with the brain, producing permanent vision impairment.
She explained that clearing the obstructed vision, whether from a capillary hemangioma or any periorbital growth, should be considered urgent to avoid irreversible damage.
Similarly, periorbital port-wine stains associated with Sturge-Weber syndrome, which is primarily a vascular disorder that predisposes children to glaucoma, represents a condition that requires prompt attention. Sturge-Weber syndrome is often but not always identified at birth, but it is a condition for which evaluation and treatment should involve the participation of an ophthalmologist.
Meibomian gland disease is another disorder that is often seen first by a pediatric dermatologist but also requires collaborative management. The challenge is sorting out the underlying cause or causes and initiating a therapy that unclogs the gland without having to resort to incision and drainage.
“Drainage is hard to do and is not necessarily effective,” explained Dr. Grace. While scrubs, warmth, and massage frequently are adequate to unclog the gland – which secretes meibum, a complex of lipids that perform several functions in protecting the eye – therapies specific to the cause, such as Demodex-related blepharitis, chalazions, and styes, might be needed.
Dr. Grace indicated that patience is often needed. The process of unclogging these glands often takes time, but she emphasized that a first-line conservative approach is always appropriate to avoid the difficulty and potential problems of incisions.
In general, these messages are not novel, but they provide a refresher for pediatric dermatologists who do not regularly confront complications that involve the eyes. According to session moderator, Elizabeth Neiman, MD, assistant professor of pediatric dermatology, University of North Carolina at Chapel Hill, the messages regarding topical steroids on the face and the eyes are “important” and worth emphasizing.
“It’s useful to reinforce the point that corticosteroids should be used when needed in the periorbital area [to control skin diseases] if they are used in low concentrations,” Dr. Neiman told this news organization.
Similarly, conjunctivitis and other ocular complications of dupilumab are a source of concern for parents as well as dermatologists. Dr. Neiman indicated that a review of the benefit-to-risk ratio is important when considering these treatments in patients with indications for severe skin disorders.
Dr. Grace and Dr. Nieman have no potential financial conflicts related to this topic.
A version of this article first appeared on Medscape.com.
ASHEVILLE, N.C. – The, according to one of several clinical messages from a pediatric ophthalmologist who spoke at the annual meeting of the Society for Pediatric Dermatology.
“There is a lot of steroid fear out there, which you can argue is actually harmful in itself, because not treating periorbital eczema is related to a lot of eye problems, including chronic discomfort and the eye rubbing that can cause corneal abrasions and keratoconus,” said Sara Grace, MD, a pediatric ophthalmologist who is on the clinical staff at Duke University, Durham, N.C. She maintains a practice at North Carolina Eye, Ear, Nose, and Throat in Durham.
Although the risks of periorbital steroid absorption are real, a limited course of low potency topical steroids is generally adequate for common periorbital indications, and these appear to be safe.
“There is insufficient evidence to link weak periocular topical corticosteroids such as desonide or hydrocortisone with ocular complications,” said Dr. Grace, suggesting that pediatric dermatologists can be reassured when using these medications at low concentrations.
“Potent periocular steroids have been associated with ocular complications, but this has typically involved exposures over months to years,” Dr. Grace specified.
When topical corticosteroids are applied at high concentrations on the face away from the periorbital area, glaucoma and other feared ophthalmic complications cannot be entirely ruled out, but, again, the risk is low in the absence of “very large quantities” of potent topical agents applied for lengthy periods of time, according to Dr. Grace, basing this observation on case studies.
In children, as in adults, the potential exception is a child with existing ocular disease. In such cases, or in children with risk factors for ocular disease, Dr. Grace recommends referral to an ophthalmologist for a baseline examination prior to a course of topical corticosteroids with the potential of periocular absorption. With a baseline assessment, adverse effects are more easily documented if exposure is prolonged.
The message, although not identical, is similar for use of dupilumab (Dupixent) or other biologics that target the interleukin-13 (IL-13) pathway. The potential for complications cannot be ignored but these are often time-limited and the benefit is likely to exceed the risk in children who have severe atopic dermatitis or other skin conditions for which these treatments are effective.
There are several potential mechanisms by which biologics targeting IL-13 might increase risk of ocular complications, one of which is the role that IL-13 plays in ocular mucus production, regulation of conjunctival goblet cells, and tear production, according to several published reports.
“Up to 30% of children will get some type of eye complication but, fortunately, most of them will not have to stop therapy,” Dr. Grace said. These side effects include conjunctivitis, blepharitis, keratitis, dry eye, and itching, but they are typically manageable. Topical steroids or calcineurin inhibitors can be offered if needed, but many of these conditions will self-resolve. Dr. Grace estimated that less than 1% of patients need to stop treatment because of ophthalmic side effects.
Lesions that obstruct vision
Dr. Grace urged pediatric dermatologists to be aware of the risk for amblyopia in young children with lesions that obstruct vision in one eye. In early development, prolonged obstruction of vision in one eye can alter neural communication with the brain, producing permanent vision impairment.
She explained that clearing the obstructed vision, whether from a capillary hemangioma or any periorbital growth, should be considered urgent to avoid irreversible damage.
Similarly, periorbital port-wine stains associated with Sturge-Weber syndrome, which is primarily a vascular disorder that predisposes children to glaucoma, represents a condition that requires prompt attention. Sturge-Weber syndrome is often but not always identified at birth, but it is a condition for which evaluation and treatment should involve the participation of an ophthalmologist.
Meibomian gland disease is another disorder that is often seen first by a pediatric dermatologist but also requires collaborative management. The challenge is sorting out the underlying cause or causes and initiating a therapy that unclogs the gland without having to resort to incision and drainage.
“Drainage is hard to do and is not necessarily effective,” explained Dr. Grace. While scrubs, warmth, and massage frequently are adequate to unclog the gland – which secretes meibum, a complex of lipids that perform several functions in protecting the eye – therapies specific to the cause, such as Demodex-related blepharitis, chalazions, and styes, might be needed.
Dr. Grace indicated that patience is often needed. The process of unclogging these glands often takes time, but she emphasized that a first-line conservative approach is always appropriate to avoid the difficulty and potential problems of incisions.
In general, these messages are not novel, but they provide a refresher for pediatric dermatologists who do not regularly confront complications that involve the eyes. According to session moderator, Elizabeth Neiman, MD, assistant professor of pediatric dermatology, University of North Carolina at Chapel Hill, the messages regarding topical steroids on the face and the eyes are “important” and worth emphasizing.
“It’s useful to reinforce the point that corticosteroids should be used when needed in the periorbital area [to control skin diseases] if they are used in low concentrations,” Dr. Neiman told this news organization.
Similarly, conjunctivitis and other ocular complications of dupilumab are a source of concern for parents as well as dermatologists. Dr. Neiman indicated that a review of the benefit-to-risk ratio is important when considering these treatments in patients with indications for severe skin disorders.
Dr. Grace and Dr. Nieman have no potential financial conflicts related to this topic.
A version of this article first appeared on Medscape.com.
AT SPD 2023
Intensely pruritic rash
The history and findings in this case are consistent with atopic dermatitis (AD).
AD is a chronic inflammatory skin condition that affects more than 200 million people worldwide, including as many as 30% of children and 10% of adults. Although it is more common in children (and may persist into adulthood), approximately 1 in 4 adults with AD have adult-onset disease.
The etiology of AD is complex and includes both genetic and environmental factors, including a weakened skin barrier, immune dysregulation, and abnormalities of the skin microbiome. AD is a member of the atopic triad (ie, AD, allergic rhinoconjunctivitis, and asthma), which may commence concurrently or in succession in what is referred to as the "atopic march."
The presentation of adult-onset AD may differ from that seen in children. For example, the most commonly reported body regions affected in adult-onset AD are the hands, eyelids, neck, and flexural surfaces of the upper limbs. In contrast, childhood-onset AD is less specific to body regions other than flexural areas. Xerosis is a prominent feature, and lichenification may be present. Some patients may have a rippled, brown macular ring around the neck, simulating the pigmentations seen in macular amyloid but due instead to postinflammatory melanin deposition. Pruritus is the most common and bothersome symptom associated with AD; patients may also experience anxiety, depression, and sleep disturbances.
Diminished quality of life, reduced productivity at work and school, and increased healthcare costs (hospitalizations, emergency visits, outpatient visits, and medications) have all been reported in patients with AD. Triggers for flare-ups vary among individuals; commonly reported triggers include physical or emotional stress, changes in temperature or humidity, sweating, allergens, and irritants.
AD is typically diagnosed clinically given the characteristic distribution of lesions in various age groups (infancy, childhood, and adult). Associated findings such as keratosis pilaris may help to facilitate the diagnosis. No biomarker for the diagnosis of AD has been found and laboratory testing is rarely necessary. However, a swab of infected skin may help to isolate a specific involved organism (eg, Staphylococcus or Streptococcus) and antibiotic sensitivity. Allergy and radioallergosorbent testing are not necessary to make the diagnosis. A swab for viral polymerase chain reaction may be beneficial to help identify superinfection with herpes simplex virus and identify a diagnosis of eczema herpeticum. Testing for serum IgE level can also be helpful for supporting the diagnosis of AD.
The management of AD includes trigger avoidance, daily skin care with application of emollients, anti-inflammatory therapy, and other complementary modalities. For mild or moderate AD, first-line treatment consists of topical anti-inflammatory ointments and creams, including topical corticosteroids, which are available in a broad range of potencies. Other topical medications include topical calcineurin inhibitors (tacrolimus and pimecrolimus for patients aged ≥ 2 years), which may be particularly appropriate when there is concern for adverse events secondary to corticosteroid use; topical phosphodiesterase 4 inhibitor (crisaborole ointment for patients aged ≥ 3 months); and topical Janus kinase inhibitor (ruxolitinib cream for patients aged ≥ 12 years).
For patients with moderate to severe AD, or for those who are refractory to topical medications, treatment may include biologic therapy (dupilumab and tralokinumab for patients aged ≥ 6 months and ≥ 18 years, respectively), oral Janus kinase inhibitors (upadacitinib and abrocitinib for patients ages ≥ 12 and ≥ 18 years, respectively), phototherapy (commonly narrow-band ultraviolet light type B treatment), and oral immunomodulators (including methotrexate, mycophenolate, and azathioprine). Combination therapy may be required for the long-term management of more severe AD.
William D. James, MD, Professor, Department of Dermatology, University of Pennsylvania, Philadelphia.
Disclosure: William D. James, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: Elsevier.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
The history and findings in this case are consistent with atopic dermatitis (AD).
AD is a chronic inflammatory skin condition that affects more than 200 million people worldwide, including as many as 30% of children and 10% of adults. Although it is more common in children (and may persist into adulthood), approximately 1 in 4 adults with AD have adult-onset disease.
The etiology of AD is complex and includes both genetic and environmental factors, including a weakened skin barrier, immune dysregulation, and abnormalities of the skin microbiome. AD is a member of the atopic triad (ie, AD, allergic rhinoconjunctivitis, and asthma), which may commence concurrently or in succession in what is referred to as the "atopic march."
The presentation of adult-onset AD may differ from that seen in children. For example, the most commonly reported body regions affected in adult-onset AD are the hands, eyelids, neck, and flexural surfaces of the upper limbs. In contrast, childhood-onset AD is less specific to body regions other than flexural areas. Xerosis is a prominent feature, and lichenification may be present. Some patients may have a rippled, brown macular ring around the neck, simulating the pigmentations seen in macular amyloid but due instead to postinflammatory melanin deposition. Pruritus is the most common and bothersome symptom associated with AD; patients may also experience anxiety, depression, and sleep disturbances.
Diminished quality of life, reduced productivity at work and school, and increased healthcare costs (hospitalizations, emergency visits, outpatient visits, and medications) have all been reported in patients with AD. Triggers for flare-ups vary among individuals; commonly reported triggers include physical or emotional stress, changes in temperature or humidity, sweating, allergens, and irritants.
AD is typically diagnosed clinically given the characteristic distribution of lesions in various age groups (infancy, childhood, and adult). Associated findings such as keratosis pilaris may help to facilitate the diagnosis. No biomarker for the diagnosis of AD has been found and laboratory testing is rarely necessary. However, a swab of infected skin may help to isolate a specific involved organism (eg, Staphylococcus or Streptococcus) and antibiotic sensitivity. Allergy and radioallergosorbent testing are not necessary to make the diagnosis. A swab for viral polymerase chain reaction may be beneficial to help identify superinfection with herpes simplex virus and identify a diagnosis of eczema herpeticum. Testing for serum IgE level can also be helpful for supporting the diagnosis of AD.
The management of AD includes trigger avoidance, daily skin care with application of emollients, anti-inflammatory therapy, and other complementary modalities. For mild or moderate AD, first-line treatment consists of topical anti-inflammatory ointments and creams, including topical corticosteroids, which are available in a broad range of potencies. Other topical medications include topical calcineurin inhibitors (tacrolimus and pimecrolimus for patients aged ≥ 2 years), which may be particularly appropriate when there is concern for adverse events secondary to corticosteroid use; topical phosphodiesterase 4 inhibitor (crisaborole ointment for patients aged ≥ 3 months); and topical Janus kinase inhibitor (ruxolitinib cream for patients aged ≥ 12 years).
For patients with moderate to severe AD, or for those who are refractory to topical medications, treatment may include biologic therapy (dupilumab and tralokinumab for patients aged ≥ 6 months and ≥ 18 years, respectively), oral Janus kinase inhibitors (upadacitinib and abrocitinib for patients ages ≥ 12 and ≥ 18 years, respectively), phototherapy (commonly narrow-band ultraviolet light type B treatment), and oral immunomodulators (including methotrexate, mycophenolate, and azathioprine). Combination therapy may be required for the long-term management of more severe AD.
William D. James, MD, Professor, Department of Dermatology, University of Pennsylvania, Philadelphia.
Disclosure: William D. James, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: Elsevier.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
The history and findings in this case are consistent with atopic dermatitis (AD).
AD is a chronic inflammatory skin condition that affects more than 200 million people worldwide, including as many as 30% of children and 10% of adults. Although it is more common in children (and may persist into adulthood), approximately 1 in 4 adults with AD have adult-onset disease.
The etiology of AD is complex and includes both genetic and environmental factors, including a weakened skin barrier, immune dysregulation, and abnormalities of the skin microbiome. AD is a member of the atopic triad (ie, AD, allergic rhinoconjunctivitis, and asthma), which may commence concurrently or in succession in what is referred to as the "atopic march."
The presentation of adult-onset AD may differ from that seen in children. For example, the most commonly reported body regions affected in adult-onset AD are the hands, eyelids, neck, and flexural surfaces of the upper limbs. In contrast, childhood-onset AD is less specific to body regions other than flexural areas. Xerosis is a prominent feature, and lichenification may be present. Some patients may have a rippled, brown macular ring around the neck, simulating the pigmentations seen in macular amyloid but due instead to postinflammatory melanin deposition. Pruritus is the most common and bothersome symptom associated with AD; patients may also experience anxiety, depression, and sleep disturbances.
Diminished quality of life, reduced productivity at work and school, and increased healthcare costs (hospitalizations, emergency visits, outpatient visits, and medications) have all been reported in patients with AD. Triggers for flare-ups vary among individuals; commonly reported triggers include physical or emotional stress, changes in temperature or humidity, sweating, allergens, and irritants.
AD is typically diagnosed clinically given the characteristic distribution of lesions in various age groups (infancy, childhood, and adult). Associated findings such as keratosis pilaris may help to facilitate the diagnosis. No biomarker for the diagnosis of AD has been found and laboratory testing is rarely necessary. However, a swab of infected skin may help to isolate a specific involved organism (eg, Staphylococcus or Streptococcus) and antibiotic sensitivity. Allergy and radioallergosorbent testing are not necessary to make the diagnosis. A swab for viral polymerase chain reaction may be beneficial to help identify superinfection with herpes simplex virus and identify a diagnosis of eczema herpeticum. Testing for serum IgE level can also be helpful for supporting the diagnosis of AD.
The management of AD includes trigger avoidance, daily skin care with application of emollients, anti-inflammatory therapy, and other complementary modalities. For mild or moderate AD, first-line treatment consists of topical anti-inflammatory ointments and creams, including topical corticosteroids, which are available in a broad range of potencies. Other topical medications include topical calcineurin inhibitors (tacrolimus and pimecrolimus for patients aged ≥ 2 years), which may be particularly appropriate when there is concern for adverse events secondary to corticosteroid use; topical phosphodiesterase 4 inhibitor (crisaborole ointment for patients aged ≥ 3 months); and topical Janus kinase inhibitor (ruxolitinib cream for patients aged ≥ 12 years).
For patients with moderate to severe AD, or for those who are refractory to topical medications, treatment may include biologic therapy (dupilumab and tralokinumab for patients aged ≥ 6 months and ≥ 18 years, respectively), oral Janus kinase inhibitors (upadacitinib and abrocitinib for patients ages ≥ 12 and ≥ 18 years, respectively), phototherapy (commonly narrow-band ultraviolet light type B treatment), and oral immunomodulators (including methotrexate, mycophenolate, and azathioprine). Combination therapy may be required for the long-term management of more severe AD.
William D. James, MD, Professor, Department of Dermatology, University of Pennsylvania, Philadelphia.
Disclosure: William D. James, MD, has disclosed the following relevant financial relationships:
Received income in an amount equal to or greater than $250 from: Elsevier.
Image Quizzes are fictional or fictionalized clinical scenarios intended to provide evidence-based educational takeaways.
A 52-year-old woman presents with complaints of an itchy rash on her arms, legs, neck, and eyelids. She reports having flares with a similar eruption on her arms and legs over the past 2 years, but on previous occasions she was able to manage it with topical emollients. Over the past 6 months, however, it has worsened both in intensity and spread. She describes the rash as intensely pruritic, and now that it has become more visible, she reports feeling embarrassed by it at work and during social outings. The itch is also disrupting her sleep. The patient states that she is undergoing an extremely stressful period in her life because of her parents' declining health and a recent separation from her husband.
Approximately 3 months ago, she visited her primary care provider, who diagnosed her with an allergic rash and prescribed a course of an oral glucocorticoid. Initially, she thought the treatment worked, but the rash soon recurred after she finished her treatment.
Physical examination reveals scaly, crusted hyperpigmented lesions involving the arms, flexural areas of the elbows and knees, neck, and eyelids. Lichenification and xerosis are observed. There is no evidence of conjunctivitis or scalp involvement. The turbinates are not inflamed. Complete blood count findings are within normal range. The patient is 5 ft 3 in and weighs 125 lb (BMI 22.1) and is a nonsmoker.
