By Danielle Dubin, MD, as told to Hallie Levine
Treatment for atopic dermatitis, also known as eczema, has made leaps and bounds over the years. A half-century ago, doctors relied on topical and oral steroids to treat atopic dermatitis (AD), which came with all sorts of unpleasant side effects. Today, we have many treatments targeted to AD that are both safe and effective.
I’m proud to be part of the team at the Eczema Center for Excellence at the Mount Sinai Health System. Here, we’ve pioneered some of the most cutting-edge treatments for eczema. Our research led to the understanding that AD is an immune disease. This opened the door for us to explore all kinds of new treatments.
Groundbreaking New Treatments
My team at Mount Sinai was involved in the initial clinical trials for dupilumab (Dupixent), the first biologic approved by the FDA for atopic dermatitis. It’s a genetically engineered, targeted therapy that blocks the action of two chemicals in your immune system: IL-4 and IL-13. Both cause skin inflammation in people with AD.
Dupilumab was considered a true game changer because it was the first drug available to target inflammatory chemicals directly involved in the eczema pathway. It was unique because it addressed the root cause of eczema, rather than simply treating symptoms. It’s also very well-tolerated by patients. The main side effects are dry eye and conjunctivitis, or some slight redness or swelling around the injection site. More rarely, you can develop joint pain. It also slightly increases your risk of developing cold sores from the herpes virus.
Since the FDA approval of dupilumab in 2017, other biologics have become available. These include:
- Lebrikizumab (Ebglyss). This drug was approved earlier this year. It also blocks IL-13.
- Tralokinumab (Adbry). It blocks the inflammatory chemical IL-13.
All three drugs are given as a shot, either by you or at your doctor’s office.
There’s also another new class of drugs available, known as Janus kinase (JAK) inhibitors. They block specific proteins called JAK proteins, which trigger the release of chemicals that cause the red, itchy skin in eczema. There are three JAK inhibitors currently FDA-approved for AD in the United States:
- Abrocitinib (Cibinqo), taken as a pill
- Ruxolitinib (Opzelura), applied as a cream
- Upadacitinib (Rinvoq), taken as a pill
We use these drugs in people ages 12 years and older whose atopic dermatitis hasn’t responded to other drugs such as biologics. We like them because they’ll knock out any AD in people who don’t get better with other therapies. But they have a lot of side effects. They may suppress your immune system. This makes it more likely that you’ll get sick with a respiratory virus, or develop an ear or urinary tract infection. Much more rarely, you can develop blood clots, pneumonia, or tuberculosis. We usually see these serious side effects among patients who use different JAK inhibitors approved for other conditions such as rheumatoid arthritis. But they can theoretically happen with any of them.
What’s on the Horizon
All these new therapies to treat AD are great. But they aren’t perfect. There’s always room for improvement and advancement. Our goal is to find the most targeted treatments possible. Ideally, this will give us the best results, with the least amount of side effects.
Thankfully, there’s some very exciting research on the horizon. Here’s a closer look at what will soon come down the pike:
Nemolizumab (Nemluvio): This drug was FDA-approved this past August to treat prurigo nodularis (PN), a skin disorder that causes hard, itchy bumps. It’s a monoclonal antibody that inhibits IL-31, a protein that triggers signals to your brain that cause you to itch. You take it at home once a month as a shot you give yourself. New research now suggests that it can also reduce the inflammation and itching in adults and teens with moderate or severe atopic dermatitis. The hope is that it will be FDA-approved for AD within the next couple of years.
Rocatinlimab: This experimental drug is known as an anti-OX40 antibody. It’s thought that in people with AD, T cells, a type of white blood cells, play a role in the condition. They trigger an overactive immune response that causes an eczema flare. New research shows that if you target and inhibit a particular receptor on the T cells, known as OX40, it can help to break this cycle. At Mount Sinai, we’ve done small studies that have found that rocatinlimab can help to relieve symptoms of atopic dermatitis, and it appears safe. We’re now recruiting patients for a larger clinical trial.
TSLP inhibitor: A substance called thymic stromal lymphopoietin (TSLP) also plays a role in atopic dermatitis. It activates immune cells that cause skin inflammation. My Mount Sinai team is currently studying a drug to inhibit TSLP. This is still in the very early stages, but the hope is that it could be even more effective than a biologic such as Dupixent, with even fewer side effects.
Those are just the projects we are involved with here at Mount Sinai. You can find out more about other drugs in development by searching the National Eczema Association’s clinical trial database here.
Digging Into the Root Causes of Atopic Dermatitis
The more we learn about AD, the more we realize that it’s a very complicated disease. There’s not just one cause of the condition. There are specific genes involved, like the FLG gene, which produces a substance in your skin called filaggrin. Certain variations in these genes make you more likely to have eczema. We also know there are several chemicals that cause inflammation that leads to AD. The more we learn about these chemicals and their pathways, the more likely we are to be able to develop targeted treatments to address them.
The hope is that one day, we’ll be able to run a bunch of blood and skin tests on people with eczema, look for certain inflammatory markers, and then develop a personalized treatment plan for them. I’m also hopeful that we will be able to combine therapies to target multiple inflammatory pathways. This would mean we could use lower dosages, for greater efficacy and fewer side effects. The future for people with AD has never looked so bright.
In the meantime, if you or a loved one has atopic dermatitis, there’s no need to suffer silently at home. Untreated eczema can affect your sleep, your self-esteem, your mood, and even your school and work performance. So many treatments are available now. You and your doctor will be able to find something that works for you.
Show Sources
Photo Credits: iStock/Getty Images, Danielle Dublin, MD.
SOURCES:
Danielle Dubin, MD, assistant professor of dermatology, Icahn School of Medicine at Mount Sinai Hospital, New York City.
UpToDate: “Treatment of Atopic Dermatitis (Eczema).”
The Lancet: “An Anti-OX40 Antibody to Treat Moderate-to-Severe Atopic Dermatitis: A Multicentre, Double-Blind, Placebo-Controlled Phase 2B Study.”
