The Exchange

Commentary and Observations from
the Medical Front Lines

Using Biologic Therapy for Moderate to Severe Atopic Dermatitis

Using Biologic Therapy for Moderate to Severe Atopic Dermatitis

As mentioned in my previous post this week, atopic dermatitis (AD) affects more than 9.6 million children and about 16.5 million adults in the United States. It is a chronic condition that can go through periods of flare and remission throughout a patient's lifetime, and can have a significant negative impact on quality of life for both the patient and their family/caregivers. The inflammation and skin barrier damage typically seen in patients with AD is due to triggers—such as environmental allergens—causing an overactive immune response. The hallmark sign is itching; erythematous scaling patches and plaques can develop anywhere on the body, with the antecubital and popliteal fossa being the most common locations. Skin can become dry and discolored, and repeated scratching can cause thickening known as lichenification; the affected skin is at an increased risk for infection.

When AD is mild, management may include avoiding known triggers, maintaining a regular bathing and moisturizing routine to protect and strengthen the skin barrier, getting high-quality sleep, eating a healthy diet, and managing stress. Moderate to severe AD can be debilitating and often requires use of systemic therapy to achieve adequate disease control.

AD pathophysiology includes the inappropriate activation and increase of type 2 cytokines in the skin, including interleukin (IL)-13 and IL-4. In March 2017, dupilumab, a human anti–IL-4Rα antibody, became the first biologic to receive approval in the United States for the treatment of moderate to severe AD. It is indicated for the treatment of patients aged 6 years and older whose disease is not adequately controlled with other therapies. It acts by blocking IL-4 and IL-13 from binding to their cell receptors, lowering the severity of inflammation and decreasing the symptoms of AD.

Dupilumab is given by subcutaneous injection; the recommended dosing for adult patients is an initial dose of 600 mg (two 300 mg injections), followed by 300 mg given every other week. The recommended dosing for patients 6 to 17 years of age is initially either 200 mg or 300 mg (given twice daily for a total of 400 mg and 600 mg, respectively), followed by 200 mg or 300 mg every 2 to 4 weeks, depending on body weight (see prescribing information). Dupilumab is not considered an immunosuppressant, does not require any lab monitoring, and the most common reported adverse events in clinical trials were injection site reactions and conjunctivitis. However, since it is a biologic therapy, patients taking it should avoid live vaccines. Additionally, patients who are pregnant or considering pregnancy should be informed regarding the benefits versus the risks prior to beginning therapy with dupilumab. However, available reports on use in pregnant women have not identified a drug-associated risk of adverse maternal or fetal outcomes. Dupilumab has shown short- and long-term positive results in clinical outcomes, as well as in patient-reported outcomes, for the management of AD.

  • Dupilumab [prescribing information]. Tarrytown, NY: Regeneron Pharmaceuticals, Inc; 2021.
  • Moyle M, et al. Understanding the immune landscape in atopic dermatitis: The era of biologics and emerging therapeutic approaches. Exp Dermatol. 2019;28:756-768.
  • National Eczema Association. Atopic dermatitis. Accessed April 1, 2021.

Filed under: Allergy/Immunology, Dermatology

Development Widget