Journal Club: Updates in Topical Treatments for AD

Dr. Peter A. Lio:
Hello, everyone and welcome to Atopic Dermatitis Journal Club. I'm very excited to be here today. I'm Peter Lio, I'm a clinical assistant professor of dermatology and pediatrics at Northwestern University in Chicago, Illinois.

Dr. Ted Lain:
And I'm Ted Lain. I'm a board-certified dermatologist in Austin, Texas, with Sanova Dermatology and we would like to thank our sponsor, Practical Dermatology, to really have us present on the AD Journal Club, really focusing on the new topical therapeutics that we have for atopic dermatitis, which Peter, thankfully, we have quite a few.

Dr. Peter A. Lio:
We do. After an incredibly long period where there was a drought, so to speak, with the initial release of topical steroids in the 1950s. And I always tell that story of my teacher who was practicing dermatology before they had topical steroids. We said, "Dr. Michelo, what did you use to do?" And he said, "A lot of petrolatum." To the long gap to the year 2000 and 2001, respectively, when we got, of course, our calcineurin inhibitors tacrolimus and pimecrolimus and then another 15 years before we got the beginning of a new era.

Dr. Ted Lain:
And that new era started with the PDE4 inhibitor crisaborole, right? Which had that boron atom and really fit in lock and key mechanism to inhibit that PDE4 enzyme. I remember we were part of the phase 3 trials for that drug, we were so excited to have the non-steroidal alternative and then it hit the market and we started getting a lot of stinging and burning, which really scared people quite a bit, but I think we figured out how to use it. Now, if you keep it in the fridge cold, you apply it to an unaffected area first to make sure people aren't having any of that stinging and burning. I think there is definitely a place for crisaborole in our atopic dermatitis armamentarium, but now there's an even newer PDE4 inhibitor, right?

Dr. Peter A. Lio:
Yes. Such big news in the past year, here now we have a topical PDE4 inhibitor that is a little bit different than the crisaborole in that it's once daily, it's a cream base. And our experience, I think both of us, we've been talking about it quite a bit recently, has been very different. It's been incredibly well tolerated. And this, of course, is roflumilast.

Dr. Ted Lain:
That's right. Roflumilast, brand name is ZORYVE. And this company has done a great job, right? They came out with roflumilast for atopic dermatitis, then they did the foam for seborrheic dermatitis. Now we've got... Actually, they came out for psoriasis, excuse me. Now we have the foam for seborrheic dermatitis and now we've got the 0.15% for atopic dermatitis. So really nice life cycle management of this molecule to allow us to use the same molecule on three of the most common inflammatory skin disorders that we deal with and really the once daily application cannot be stressed enough. It's just so easy for our patients.

Dr. Peter A. Lio:
It really is and I feel like, to me, it was the answer to a wish. We've always wanted something that was non-steroidal, pretty gentle, that could be used more in a... I think of it as a proactive or maintenance mode, where maybe they'd still use their topical steroid or maybe this is a good time to talk about our other big new topical, which is a topical JAK inhibitor, ruxolitinib, and that's been really exciting, too. That came out a little bit before our roflumilast did and, of course, the brand name there is OPZELURA and that one I love because it's a nonsteroidal agent that packs a real punch, twice daily application, of course, down to age 12 with that particular medication.

Of course, with roflumilast, down to age 6 for psoriasis and atopic dermatitis, but really powerful. And my favorite study is where they had an active comparator group against the ruxolitinib, which was triamcinolone, a mid-potency steroid, a workhorse. And it actually did every bit as good and arguably numerically it was a little better. Of course, it wasn't powered to show superiority, but it really did hold its own and I feel like now we have a couple of big new options in the pipeline coming.

Dr. Ted Lain:
It's interesting with the OPZELURA in particular, right? We started using it on some of the easier to treat atopic dermatitis, thinking, "Oh, this is a sweet little nonsteroidal alternative. Let's try and use on some nummular eczema." And then we saw it doing such a great job. "Okay, let's start using it on more of the lichenified eczema." Did a great job. "What about palmoplantar eczema?" Doing a great job. And so I feel like this is one of those drugs that you could really throw at any type of eczema and get some really nice results. Again, allowing us to avoid the use of topical corticosteroids. But you're right, we do have a pipeline and unfortunately tapinarof, which, of course, we know as VTAMA for psoriasis, has some great data for atopic dermatitis, but it was recently delayed by the FDA.

Dr. Peter A. Lio:
And I agree, the data is spectacular. I can't wait to get it in my hands because it really seems like yet another promising... And again, a once daily option, which is really fantastic. I feel like for the past few years we've heard about it as having the potential to at least open the discussion about a remittive effect, where people could treat for a while and then even when they stop, they might be in a quieter state and I just love that idea. My patients love that idea, that maybe they wouldn't have to use something all the time, that once they're better, they might be able to take a respite and I just absolutely love it. We will see. The FDA has been challenging. We've had a couple of big medications in the atopic dermatitis space that have been delayed. Usually it doesn't seem like it's a safety or an efficacy issue, it usually seems like there's secondary issues. So hopefully they'll get this sorted out quickly.

Dr. Ted Lain:
If we're going to round out what's coming in the pipeline for topical therapeutics, we should talk about the palmoplantar topical JAK by Leo Pharmaceuticals as well.

Dr. Peter A. Lio:
It is really exciting and I've been following that a long time. We've been waiting for this other one. It'd be so cool. It sounds like it's going to be formulated in an ointment base, which will make it something a little different than our ruxolitinib and yeah, designed for palmoplantar areas, which is fantastic.

Dr. Ted Lain:
Yeah, so I just think that we have such a great tool chest now of topical therapeutics. Again, avoiding topical steroids. Not to say that topical steroids don't have a place, they'll always have a place, but I think to your point, this is a condition that's chronic. We can't cure it yet. And so the idea is that we're going to need something that can be used on and off for many years at this point. And so having the ability to both have a remittive effect or perhaps go down to twice a week to prevent a flare is just really wonderful for patients.

So I'm Dr. Ted Lain and I'm so excited to be with my good friend Dr. Peter Lio. This is the Practical Dermatology AD Journal Club. We've just reviewed many of the currently available topical therapeutics, those in the pipeline as well. And I think you can at least hear our enthusiasm for what's available and what's to come in this really common inflammatory skin disease, Peter.

Dr. Peter A. Lio:
Absolutely. Thank you so much, Ted. It's a pleasure as always.

Dr. Ted Lain:
Thanks, everybody.