In this episode of Topical Conversations, Dr James Del Rosso and Dr Alexandra Golant explore the nuanced use of dupilumab in treating moderate atopic dermatitis (AD), particularly in long-term management. Their discussion provides valuable perspectives on patient education, managing treatment expectations, and the unique benefits of dupilumab for both pediatric and adult patients with AD. 

A paradigm shift in AD management 

Dr Golant highlights the impactful effect of dupilumab in treating AD, describing it as a major milestone in dermatology. Since its approval, dupilumab has significantly enhanced disease control for patients, with many individuals remaining clear for years. Initially approved for adults, dupilumab has extended its reach, now approved for use in children as young as 6 months. 

Addressing parental concerns in pediatric patients 

When discussing the treatment of young children, Dr Del Rosso posits a scenario where a one-year-old patient’s parents have attempted topical steroids or nonsteroidal therapies without success. Dr Golant emphasizes the importance of educating parents about the systemic nature of AD to create a more receptive environment for systemic therapy discussions. She refers to this as “disease state re-education,” which involves explaining AD's systemic inflammatory nature and discussing how dupilumab works to address inflammation on multiple fronts. 

Explaining Systemic Therapy to Parents 

For parents open to considering systemic therapy, Dr Golant often addresses the common concern of treatment duration, especially in younger patients. With dupilumab, the goal is not only to manage AD symptoms but to potentially influence the “atopic march” or the progression of allergic diseases over time. However, she notes that long-term outcomes are still being studied, particularly in infants and young children. 

Overcoming injection concerns 

Dr Del Rosso acknowledges that the injectable nature of dupilumab may initially deter some parents. However, he points out that the biweekly dosing schedule makes treatment less burdensome than the daily application of topical therapies. Dr Golant finds that once parents see the positive results, their hesitancy often diminishes, as they realize the level of control that systemic therapy can offer. 

The role of topicals in conjunction with systemic therapy 

While dupilumab allows many patients to reduce their reliance on topicals, Dr Golant describes them as “touch-up paint” for spot treatments that may still be necessary. In clinical practice, these topicals—such as corticosteroids and calcineurin inhibitors—are often used alongside dupilumab to help manage flare-ups or persistent areas of inflammation. 

Recognizing moderate AD as worthy of systemic intervention 

Dr Golant emphasizes that moderate AD can still have a high impact on patients' quality of life, even when the body surface area (BSA) affected is relatively low. For instance, severe eczema on the hands or face can cause significant discomfort and disrupt sleep, impacting daily life considerably. Dr Golant believes that patients with moderate AD often benefit substantially from systemic treatments like dupilumab and stresses the importance of assessing AD's impact on quality of life, rather than focusing solely on BSA affected. 

Dupilumab’s benefit for comorbid conditions 

One significant advantage of dupilumab is its efficacy across a range of atopic conditions. For patients with AD who also have nasal polyps, asthma, or eosinophilic esophagitis, dupilumab’s effects may extend to these conditions as well. Dr Golant recommends dermatologists take a thorough history to identify any additional comorbidities that dupilumab might positively impact, making it a versatile choice for many patients. 

Monitoring Progress and Setting Treatment Goals 

For tracking the progress of AD treatment in patients, Dr Del Rosso recommends the Atopic Dermatitis Control Tool as a practical and efficient way to assess symptom control. Dr Golant agrees, and also emphasized the importance of shared decision-making with patients and aligning on treatment goals and quality-of-life improvements. In follow-up visits, she discusses practical impacts on quality of life, such as improvements in sleep or reduced limitations in daily activities. 

Responding to questions on long-term use 

When asked how long patients or their children should remain on dupilumab, Dr Del Rosso explains that his approach has evolved. Rather than recommending indefinite use, he now focuses on achieving optimal disease control and leaving the decision to continue treatment flexible. This open-ended approach reassures patients and builds trust, as they can feel confident in stopping treatment if they are uncomfortable at any point. 

Key takeaways for dermatologists 

The conversation between Dr Golant and Dr Del Rosso underscores the importance of effective communication with patients and families about systemic therapy options like dupilumab. They emphasize the necessity of educating patients on the systemic nature of AD, addressing concerns around injectables, and recognizing that even moderate AD can warrant systemic treatment.