Atopic dermatitis (AD) is one of the most commonly encountered skin diseases by dermatologists. John Koo, MD, gave the audience an excellent update on the diagnosis and treatment of AD in this session. Beginning with diagnosis, Dr Koo encouraged providers to utilize “atopic dermatitis spectrum disorder” as a clinical entity more in practice. Because of the wide heterogeneity of AD, many different presentations can fall under the “atopic dermatitis spectrum disorder” umbrella, including prurigo nodularis (PN), nummular eczema, eyelid dermatitis, dyshidrosis, and chronic pruritus of the elderly. Using atopic dermatitis as a visit diagnosis for these presentations can help with medication coverage. 

Moving on to treatments for AD, Dr Koo discussed recent data showing that dupilumab has efficacy for chronic pruritus even without visible rash or inflammation, as evidenced by its recent approval for PN. Dupilumab is thought to improve the itch of PN not only by decreasing inflammation but also by blocking sensory nerve hypersensitivity through decreased IL-4 signaling. The reduction of chronic itch with JAK inhibitors is also thought to work by reducing neural hypersensitivity, thereby halting the “itch-scratch cycle.” 

To conclude, Dr Koo took a deep look at safety data for JAK inhibitors, including the rates of black box warning events in atopic dermatitis clinical trials. Both upadacitinib and abrocitinib, oral JAK-1 inhibitors approved for AD, have a black box warning for serious infection, mortality, malignancy, major adverse cardiovascular events (MACE), and thrombosis. Serious infections did not result in any deaths in one year of clinical trial data for both medications, and rates of serious infection were similar to placebo and not dose-dependent. No deaths considered related to study medication occurred in either year-long trial. Two malignancies were seen in patients treated with abrocitinib, both prostate cancer in older males, and one case of cutaneous T cell lymphoma was seen in a patient treated with upadacitinib. 

Rates of MACE and thrombosis were low in both abrocitinib and upadacitinib studies, with all cases having multiple risk factors. Adverse events with JAK inhibitors that do have evidence of being dose-dependent include herpes simplex, herpes zoster, acne, and nausea. Dr Koo left the audience with 2 safety take-home points: first, patients with AD are healthier than patients with rheumatoid arthritis (RA), and as a result, AD safety data is cleaner; second, even in patients with RA, rates of malignancy and MACE were similar between tofacitinib and adalimumab if the patient was nonelderly and did not smoke.