Dr Jonathan Silverberg on The Evolution and Treatment of Atopic Dermatitis

Jonathan Silverberg, MD, PhD, MPH, is an associate professor of dermatology and director of the patch testing clinic at the George Washington University School of Medicine and Health Sciences in Washington, DC. He is also the director of clinical research and contact dermatitis. His area of expertise is in inflammatory skin disease, focused on atopic dermatitis (AD) and contact dermatitis. He has a background in advanced management of AD, hand eczema, chronic itch, psoriasis, hidradenitis suppurativa, and other chronic inflammatory skin disorders. His subspecialty revolves around allergy patch testing, phototesting, and photopatch testing.

In this interview with The Dermatologist, Dr Jonathan Silverberg discusses the evolution of AD treatment and offers insights into how dermatologists should make considerations when choosing a treatment for patients with AD.

How has AD treatment evolved over time?

We are, arguably, in the golden era of atopic dermatitis right now, which is absolutely a beautiful thing. Just to preface, when I got started in atopic dermatitis over a decade ago, there were not so many who were passionate about it. Now, it is amazing to see the level of interest and the number of new therapies under investigation. Going back to 2017, we had an approved systemic agent, a new approved topical agent, a nonsteroidal, and now we are seeing the development of other agents as well, such as new topicals, new orals, and new injectables. I think each of these fills potential unmet need. All of the clinical and market research has shown that patients clearly prefer oral over injectable. For that reason, there is major need for safe, effective, well tolerated oral therapies in particular.

What considerations should dermatologists make when choosing a treatment for patients with AD?

Probably the best way would be this idea of shared decision making. We hear this term thrown out a lot and discussed in general, and it has its relevance in so many scenarios, but I think it is particularly relevant here. The reason is that, for all the different therapies now approved or being studied for atopic dermatitis, they each have very different looking profiles, and they each have major strengths and potential.

When we look at the biologics like dupilumab and tralokinumab, these are 2 approved options now in the US. They are very safe and highly effective medications, but you could argue that maybe one of their biggest strengths would be the safety aspect because, while there are some tolerability concerns, generally they have a very good safety profile. But there is a drawback in that they are injectables and patients often do not like shots. On the other hand, we have oral JAK-inhibitors, which are faster in terms of their onset of effect and the biologics. We have seen, especially with the higher doses, more potent efficacy in many respects, particularly with higher doses of upadacitinib and abrocitinib, but there is laboratory monitoring. There are serious adverse events that fortunately are rare, but things we have to monitor and discuss with patients.

It is a complicated discussion. It is not like there is one clear winner that wins on all of those categories. For that reason, we need to really take into account patient preference and explain all of these things to patients to see what resonates with them. I can tell you, as someone who tries to practice shared decision making, you almost cannot predict what each patient will do. Having the same discussion, one patient may say, "You know what? I want the safer drug," and another patient may say, "Doc, I have a wedding in 2 weeks. I need to be better tomorrow. I do not have any patience anymore. I cannot function. You have to give me the drug that has the highest level of efficacy, at least on paper in terms of the trials."

That is a very important aspect, which is why it is so important for clinicians to really be on top of all the data. There are important nuances in how we interpret this and how we would compare both the efficacy and the safety of these different medications. One of the parts that makes it very exciting is now being able to use these new options and then figure out who is the right patient for each of these individual therapies. I think some of that discussion around precision medicine and trying to match up who is the right patient for drug X, Y, and Z—we do not know all of those things yet, and it is really exciting figuring that out in the real world.

Want to listen to his discussion? Check out our podcast coverage here.