Atopic Dermatitis Treatment Is Evolving 

May 04, 2022

This article was originally published in French on Medscape.

PARIS — The 17th Congrès Francophone d'allergologie (CFA), a congress of French-speaking allergists, took place April 19-April 22 at the Palais des Congrès de la Porte Maillot in Paris. The session about atopic dermatitis (AD) was eagerly anticipated, given the abundance of recent research into the disease. Audrey Nosbaum, MD, PhD, a dermatologist at the Department of Allergies and Clinical Immunology, South Lyon University Hospital, France, talked about treating AD with dupilumab (Dupixent), the first systemic biologic therapy for children and teenagers.

First-Line Therapy

In 2020, European recommendations, which are published every 2 years, guided the treatment of AD. The key takeaway was that all children should use daily emollients and receive information about their treatment. "While emollients have been debated since 2014, we are strongly recommending them," said Nosbaum.

Depending on the AD severity, the algorithm in the recommendations describes other treatment options. In 2020, dupilumab, an anti-IL-4 and anti-IL-13 monoclonal antibody that inhibits the signaling pathways of these two cytokines, became available for the most severe forms of AD. "Since October 2021, hospital allergists have been authorized to issue the initial biotherapy prescription," Nosbaum clarified, encouraging the audience to "get their hands on the molecule."

What does this look like in practice? "It's a lot easier in children than in adults," said Nosbaum. In teenagers and children, dupilumab is indicated for the treatment of moderate to severe AD requiring systemic treatment. It is therefore used as first-line treatment. The baseline workup requires a complete blood count, vaccination panel, scored assessment of AD severity to determine the objective effect of the drug, and study and treatment, if needed, of parasitosis in case of persistent eosinophilia (> 1500 cells/mm3). A liver and kidney panel and specialized pulmonology and ophthalmology opinions are also sometimes required, but not as systematically as in adults.

"At the time of prescription, on an exception prescription, I recommend giving a demonstration of the injections (pen, syringe) and proposing a subcutaneous pump if the child is afraid of needles," advised Nosbaum. "It's important to explain to parents what they should expect in terms of efficacy and safety and to give them the follow-up diary, information sheet, and GREAT [a French research group for atopic dermatitis] information sheet." Minimum follow-up happens at the clinic at months 4, 8, and 12, then every 6 months. Follow-up laboratory tests are not needed.

Pediatric Efficacy and Safety

When it comes to the efficacy and safety of dupilumab, of the studies published or presented during the congress, Nosbaum described a real-world study of the combination of dupilumab and topical corticosteroids. The study, which reflected "what happens in practice," primarily aimed to "resolve" or "nearly resolve" the children's dermatitis (ie, reach an IGA score of 0 or 1 at week 16). On dupilumab, one third of children reached the primary objective of this clinical trial. "These children were dermatitis-free after 4 months of dupilumab in comparison with placebo," said Nosbaum. There are few side effects, but the rate of conjunctivitis and infection is slightly better in children than in adults.

What is happening in the field? The results of a French multicenter cohort study show that 90% of children's dermatitis was "resolved" or "nearly resolved" at month 6. "These real-world results are really very, very impressive in terms of efficacy," said Nosbaum. "The safety data are also reassuring, since conjunctivitis is identified but less frequently than in adults (11% vs 18%)."

New Systemic Treatments for Moderate to Severe AD

For teenagers aged 12-17 years:

  • dupilumab: indicated and marketed

  • upadacitinib (anti-JAK1): approved in Europe and not marketed in France

  • baricitinib (anti-JAK1 and JAK2), abrocitinib (anti-JAK1), tralokinumab (anti-IL-13, data disseminated during the congress), lebrikizumab (anti-IL-13, phase 3 trial results expected in 2022), nemolizumab (anti-IL-31, results expected in 2023): under evaluation.

For children aged 6-11 years:

  • dupilumab: indicated and marketed

  • no data available for JAK inhibitors and other biologics in this age group.

For children aged 6 months to 5 years:

  • dupilumab: data at Week 16

  • no data available for JAK inhibitors and other biologics in this age group.

Bear in mind that there is no age limit for cyclosporine (MA) and methotrexate (off-label).

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