Advances in Treatment of Atopic Dermatitis, Part 1
Atopic dermatitis (AD), the most common form of eczema, is a chronically relapsing inflammatory skin disease with a complex pathogenesis affecting up to 25% of children in industrialized countries. One-third of cases persist into adulthood, with a prevalence of 2% to 10%.1 In the United States, the prevalence of childhood eczema/AD is 10.7% overall and as high as 18.1% in individual states, according to the National Eczema Association.2 The pathogenesis of AD involves complex interactions between susceptible genes, immunologic factors, skin barrier defects, and neuroendocrine and environmental factors.3
A Challenging Disease
Because its exact cause is unknown, it is a challenging disease for dermatologists to treat and manage. “The cause of eczema/AD is complex and difficult to explain. Patients are often focused on a simple solution, such as eliminating a food from their diet, which is unlikely to improve the situation. No one wants to be told they could be dealing with a skin problem that can be for their whole life,” said Anna L. Bruckner, MD, associate professor of dermatology and pediatrics, University of Colorado School of Medicine,” in an interview with The Dermatologist.
“Most patients are not willing to acknowledge AD as a chronic condition. Proper treatment of AD requires long-term commitment to gentle skin care and use of topical corticosteroids during flares. Some patients benefit from daily use of a topical calcineurin inhibitor or phosphodiesterase inhibitor to prevent flares,” said John C. Browning, MD, MBA, FAAD, FAAP, chief of dermatology, Children’s Hospital of San Antonio.
In addition to dispelling the myths associated with chronic disease, lack of well-defined optimal treatment, and input from various sources (ie, well-meaning relatives, the internet), access to prescription medication is huge barrier, according to Elaine Siegfried, MD, professor of pediatrics and dermatology, Saint Louis University. “Payers have limited formularies and they often deny coverage for a variety of medications for kids who have skin disease. Because eczema is so common, it is among the most common denials that we get,” Dr Siegfried told The Dermatologist.
“The amount of time our office is forced to spend trying to justify the prescriptions we write and gain access to medications for our patients is growing and becoming relatively insurmountable. About 50% of my patients have eczema, but it takes 90% of my time to manage them,” she said.
Advances in Eczema/AD Treatment
Recent FDA approvals of therapies to treat eczema/AD are offering new treatment options for individuals living with skin disease. “After so many years of trying to help patients manage their disease with almost nothing that has labeling for this disease in the pediatric age group, we finally have an expanding pipeline,” noted Dr Siegfried.
In late 2106, the FDA approved crisaborole (Eucrisa) for mild to moderate AD in patients aged 2 years and older. This topical phosphodiesterase-4 (PDE4) inhibitor marked the first drug approved in 15 years for eczema. The approval of crisaborole is “very exciting as it has been studied in patients 2 and up with AD as a daily application. Treatment breaks are not required, as is with topical steroids,” said Dr Browning, who is also an assistant professor at Baylor College of Medicine.
The safety and efficacy of crisaborole were established in 2 identically designed, vehicle-controlled, double-blind, phase 3 studies (AD-301 and AD-302) with a total of 1522 participants (aged 2-79 years) with mild to moderate AD. Overall, the participants receiving crisaborole achieved greater response with clear or almost clear skin at day 29 of treatment (AD-301, 51.7% and AD-302, 48.5%). Crisaborole demonstrated a favorable safety profile and treatment-related adverse events were infrequent and mild to moderate in severity. The most common adverse event was application site pain, including burning, or stinging.4