During their session, “Atopic Dermatitis Management—Getting the Inside Track on JAKs,” James Q. Del Rosso, DO, and Elizabeth Swanson, MD, went over the current JAK inhibitors available to patients with atopic dermatitis (AD).

Dr Swanson began by highlighting 3 major JAKs currently used in practice:

• Ruxolitinib
• Abrocitinib
• Upadacitinib

For her part of the session, Dr Swanson focused on topical ruxolitinib. She shared that it is indicated for short-term and noncontinuous chronic treatment in patients aged 12 years and older with mild to moderate AD that is not controlled with other topical therapies. Additionally, its efficacy and speed of improvement is similar to topical steroids despite the fact that it is not a steroid itself.

Although Dr Swanson noted that ruxolitinib is safe for all body areas, she did ask the audience, “Has anyone else noticed crystals in the cream?” Upon echoes of confirmation from the audience, she remarked that this does seem to be a rare issue, but physicians should keep it in mind when prescribing ruxolitinib for patients.

Dr Swanson also addressed whether ruxolitinib could be combined with systemic medications with a resounding “no.” She commented that the official limitations include other JAK inhibitors and potent immunosuppressants, such as azathioprine and cyclosporine; however, there is an interest in combining ruxolitinib with dupilumab.

Finally, Dr Swanson discussed the ideal patient for topical ruxolitinib:

• Patients aged 12 years or older
• Failed topical steroids or wishes to avoid topical steroids
• Failed topical calcineurin inhibitors and/or crisaborole
• Patients with sensory processing disorders
• Patients taking dupilumab with improvement but with areas that may need periodic topical therapy

Next, Dr Del Rosso took over to review the other 2 major JAKs—abrocitinib and upadacitinib.

Abrocitinib is US Food and Drug Administration approved for patients aged 18 years and older with dosing that can start at 100 mg/day; however, this could escalate. Dr Del Rosso summarized the associated risks, including the possibility of fertility impairment in female patients. Physicians should avoid using abrocitinib if patients are breastfeeding, pregnant, or have severe renal or hepatic impairment.

Dr Del Rosso continued his presentation by introducing upadacitinib. This JAK is approved for patients aged 12 years and older, and it is even approved for psoriatic arthritis. He suggested that physicians start patients on 15 mg/day, which could escalate, but avoid usage in cases of breastfeeding, pregnancy, and severe hepatic impairment.

Dr Del Rosso concluded his presentation by imparting the next steps physicians should take regarding the clinical use of oral JAK inhibitors, starting with patient selection. He emphasized that there should be a shared discussion of the benefits and risks. A risk assessment should be done by recognizing what could exclude a patient (pregnancy, severe infections, etc.) and what approach should be taken with reasonable management of the disease state. Considering patient-related factors should aid in dosing and regimen selection, and the best way to do so is to use pretreatment screening and risk evaluations.

Finally, he stressed that follow-up monitoring is important. Physicians should utilize complete blood cell count and liver function tests periodically every 3 months alongside annual skin examinations and skin cancer detection.

Reference
Swanson E, Del Rosso J. Atopic dermatitis management—getting the inside track on JAKs. Presented at: 2022 Fall Clinical Dermatology Conference; October 20-23, 2022; Las Vegas, NV.