Atopic dermatitis (AD) is an immune-mediated inflammatory disease (IMID) known to have a number of comorbidities, including other forms of atopy. While data is limited, there may be additional associations with obesity, cardiovascular disease, and autoimmune diseases such as alopecia areata and gastrointestinal immune-mediated disorders.
Peter Lio, MD, FAAD, is clinical assistant professor of dermatology and pediatrics at Feinberg School of Medicine at Northwestern University in Chicago, IL. At the Interdisciplinary Autoimmune Summit 2021, Dr Lio spoke about emerging therapies for moderate to severe AD. In an interview with the Autoimmune Learning Network, Dr Lio answered several questions regarding advanced management of the disease.
What is thought to be link between it and the other inflammatory diseases of the atopic march?
This is an exciting and rapidly developing area. While there are clearly some genetic tendencies towards atopy, one of the newer concepts is that AD with its impaired skin barrier ("leaky skin" as I like to call it) acts as the conduit for sensitization and development of other allergies. This has most clearly been illustrated with food allergies such as peanut. The concept is that allergens can enter the skin in an abnormal fashion due to the barrier impairment allowing for transcutaneous sensitization. There is a trend towards more allergies in those with more severe AD that supports this notion as well.
You recently completed a review of therapies that failed clinical trials for AD (doi:10.1007/s40261-020-00905-7). What evidence is there for revisiting some of these options in select patient populations?
This is a very interesting area for me. Because I feel strongly that there are multiple subtypes of atopic dermatitis that we are not reliably able to separate at this point, it seems reasonable to imagine that some therapies may work only in select subtypes. However, because clinical trials look at the overall results, an unfortunate mix could mean that the key subtype is not well represented, and the overall finding could well be that the therapy did not appear to work, when in reality, it worked well but only in one group. Looking at clinical trial data, I have become extremely fascinated by the response curve: in other words, is there a group of "super responders" who did great? And a group of nonresponders? Or did everyone do a little bit better? The shape of this curve, if you will, can potentially give insight into treatments that might be more selective, and this is increasingly important as we approach more precision-based medicine.
Similarly, what therapies, whether in development or currently indicated for other IMIDs, show promise in AD?
I feel incredibly lucky to be practicing in a time when we have an incredible pipeline in development for AD! From the topical JAK inhibitors, to the oral JAK inhibitors, to new biologic agents against IL-13 and IL-31, to entirely new approaches such as the aryl-hydrocarbon receptor modulators, there are lots of new treatments that have enormous promise for treating AD. Even the PDE4 inhibitor class has new drugs in development, and this is a class that has already shown efficacy as a topical for AD.
In your opinion, what questions could other specialties (ie, gastro, rheum) ask their patients help lead to a referral to a dermatologist for suspicion of AD?
In dermatology we are lucky that our organ system is visible to everyone. Dry, itchy, and inflamed skin tends to make itself known, even to the casual observer. However, because it is a waxing and waning disease, it is very possible that on a given day, things could look fairly normal and that the diagnosis could be overlooked. I think asking about dry, itchy, and irritated skin is a good general screen to see if there are skin concerns, and having a low threshold to send to dermatology is a great idea.
Are there any other pearls you would like to share with your colleagues regarding advanced management practices in AD?
There are lots of little tips and tricks to help with adherence. One of my favorites is when patients (especially little kids) tell me that everything stings and burns on their skin, I like to gather up several of my favorite moisturizers and bring them into the room. I have them carefully apply a bit of each one to an area of skin and ask: "How does this one feel?" The best moment is when the patient says something like: "I like this one! It feels great!" and then we know that this is one that they will use!
This interview was originally posted on the Autoimmune Learning Network.View more coverage from the Interdisciplinary Autoimmune Summit 2021 by clicking here.
