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What's New in the Medicine Chest? Acne, Rosacea, Actinic Keratoses, Psoriasis, Urticaria and Other Common Dermatoses

Featuring James Del Rosso, DO | Clinical Advisor |

Adjunct Clinical Professor, Dermatology
Touro University Nevada
Henderson, NV

| Published January 26, 2024

Dr. Del Rosso led an engaging and data-driven session on new therapeutics and updated guidelines, though he did remind us that while new medications are constantly in development, many tried-and-true formulations remain the anchored in treatment algorithms. The art of medicine is determining when dupilumab, for example, remains an excellent choice, where topical corticosteroids fit into a regimen, and which patient needs something more nuanced. He started his presentation by reviewing topical medications for itchy and inflammatory conditions, such as topical ruxolitinib which shows significant impact on patient report of itch in AD in even 2 days. Topical tapinarof, an acrylic hydrocarbon receptor modulator, works by regulating Th2 cell differentiation as well as reducing resident memory T-cell generation. In 2023, an 8 week RCT in >= 2 year olds showed significant impact on IGA, EASI, and Itch scores in AD though follicular events are a pertinent side effect that can be minimized by avoiding normal skin and applying a thin layer of the ointment. Further, as a steroid sparing agent, tapinarof’s usage in intertriginous psoriasis in a phase 4 trial showing iPGA of 0 at week 12 in 65% of patients is particularly vital. Topical PDE4 inhibitors, which interrupt the inflammatory cAMP pathway, are another steroid-sparing agent, and roflumilast has shown efficacy in seborrheic dermatitis, psoriasis, and atopic dermatitis. A long-term open label extension study using roflumilast 0.15% twice weekly maintained efficacy in about 50% of patients, defined as an IGA of 0 or 1, with AD. For psoriasis, the cream at 0.3% achieved PASI 75 in 40.3% and a PASI-HD-75 in almost 60%, a more precise assessment of severity when BSA<10%. Roflumilast 0.3% foam was also used effectively for skin and scalp seborrheic dermatitis. No relation to diarrhea has been seen with the topical formulations.

Systemic players are nemolizumab, the IL-31 inhibitor, which interrupts the itch cycle at the immune and nervous system level, lebrikizumab, the IL-13 inhibitor that is a promising new injection for atopic dermatitis, and bimekizumab, the IL-17A and IL-17F inhibitor that shows dramatic clinical efficacy rapidly in plaque psoriasis, with 90% of patients achieving PASI 90 by week 16. While medications for inflammatory conditions can lessen symptoms and signs, many patients, after achieving control, wonder if treatment can be stopped and remain in remission. Dr. Del Rosso addressed this question starting with dupilumab, which has data to support prolonging dosing to every 4 weeks if atopic dermatitis is well controlled. However, new systemic medications may be able to target memory T cells which perpetuate eczema flares in atopic, but normal appearing, skin. Rocatinlimab, the OX-40 inhibitor, is one of these potentially disease-modifying drugs, as the OX40 pathway promotes differentiation of activated effector T cells into memory cells. Amlitelimab, the OX-40L inhibitor, is another such medication currently under study with 40% and 60% of patients achieving an EASI 75 at Week 16 and Week 24 respectively. These pathways may not be as rapid as JAK inhibitors, but more data is required to assess if they can truly lead to a period of disease-free remission after dosing. 


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