DAY 3 - DAILY SUMMARY
April 11, 2021
Treating Atopic Dermatitis in Kids: Symposium for Inflammatory Skin Disease 2021® Highlights
Amy Paller, MD
Dr. Paller gave an important overview of disease burden of atopic dermatitis (AD) in children, as well as new and emerging topical and systemic therapies. The burden of AD goes beyond the rashes and intense pruritus associated, affecting school productivity, mental health, sleep, risk of skin infection, and quality of life. All of these may impact the family in addition to the patient.
 
Important discussion surrounding topical agents included that many studies have now shown no increased risk of non-melanoma skin cancer or lymphoma associated with topical calcineurin inhibitors. Crisaborole was approved in March 2020 for use in infants as young as 3 months of age. Emerging topical non-steroidal anti-inflammatory agents include roflumilast, a potent PDE4 inhibitor, tapinarof (a therapeutic aryl hydrocarbon modulating agent), and topical JAK ½ inhibitors such as ruxolitinib. There may be a role for commensal bacteria which kill Staphylococcus aureus, includes Coagulase negative Staphylococcus and Gram negative Roseomonas mucosa. 
 
Relevant updates include that dupilumab (IL4R inhibitor), as of May 2020, is approved for use in kids 6 years and older. Emerging systemic agents for AD include IL-13 inhibitors (tralokinumab and lebrikizumab), IL-31 inhibitor nemolizumab, and JAK inhibitors (abrocitinib, upadacitinib, baricitinib). These emerging treatments and approvals have the potential to drastically improve treatment of AD in children and thereby disease burden as well.
Biologics in the Pipeline for Atopic Dermatitis: Symposium for Inflammatory Skin Disease 2021® Highlights
Leon Kircik, MD
Dr. Kircik gave an interesting overview of emerging biologics for atopic dermatitis (AD). AD involves Th2 pathway cytokines IL-4, IL-5, IL-13, IL-31, IL-33, and TSLP (thymic stromal lymphopoietin), which may serve as therapeutic targets.
 
Highlights included that conjunctivitis, seen with dupilumab in AD, is interestingly not seen with treatment of asthma and allergic rhinitis. Dr. Kircik also cautioned that studies for dupilumab demonstrated a small subset of patients in which dupilumab may exacerbate AD.
 
A new emerging biologic for AD, tralokinumab (fully human monoclonal IgG4 antibody) potently binds and neutralizes IL-13. Dr. Kircik reviewed its efficacy in ECZTRA 1 and 2 trials. IGA 0/1 scores were 15.8% vs 7.1% placebo in ECZTRA1, and 22.2 vs 10.9% placebo in ECZTRA2. However, he notes rescue topicals could be given early for patients, who were deemed to fail tralokinumab if they received this. In compiled data from 5 trials, 7.5% of patients experienced conjunctivitis vs 3.2% of placebo patients. The TREBLE trial for lebrikizumab, another anti-IL13 monoclonal antibody, demonstrated 33% of patients had a clear or almost clear IGA score.
 
Tezepelumab (human monoclonal antibody inhibiting TSLP) is an evolving treatment for AD. Etokimab, a selective IL33 inhibitor, showed ~25% were clear/almost clear on the IGA score, but further studies have not gotten far. 
Pearls from the AAD/NPF Psoriasis Guidelines 2019-2021: Symposium for Inflammatory Skin Disease 2021® Highlights
Jashin Wu, M.D.
As a coauthor on the AAD/NPF Psoriasis Guidelines 2019-2021, Jashin Wu, M.D., highlighted the most important takeaways from the 6 guidelines.  For biologic monitoring, there is no evidence that CBC with differential and complete metabolic panels needs to be drawn for ongoing monitoring.  For patients who are not at high risk for tuberculosis, ongoing screening should be done at your discretion (changed from the past where every year screening was recommended). 
 
Screen for psoriatic arthritis!  If psoriatic arthritis is caught early, joint damage might be halted with an approved biologic.  If a child has both psoriasis and psoriatic arthritis, screen for uveitis.  For those on long-term methotrexate, can do liver imaging instead of liver biopsy which has high morbidity and mortality.