Systemic Therapy Selection in Pediatric and Adult Atopic Dermatitis

By Tom Whitfield

More than 10% of body surface area is a clear threshold for moving a patient with atopic dermatitis to systemic therapy, according to Mark Lebwohl, MD. He estimates 10 palms of the hand as 10% of body surface area.

Mark Lebwohl, MD, is a dermatologist, Dean for Clinical Therapeutics at the Icahn School of Medicine at Mount Sinai, and Chairman Emeritus of Mount Sinai’s Department of Dermatology. He discussed pediatric and adult systemic treatment selection, where approval age and insurance access carry equal weight.

“We can’t get many of the drugs between the ages of 2 and 12 because they’re simply not approved,” Lebwohl said.

Who should move to systemic therapy?

Lebwohl said inadequate control despite topical therapy is the central criterion, rather than body surface involvement alone. His practical list includes:

• More than 10% of body surface area involved, with 10 palms of the hand serving as the 10% estimate.
• Repeated flares, including disease that leaves patients applying topical medication for much of the year.
• Limited disease that still does not respond adequately to topical treatment.

Some patients prefer to defer systemic therapy regardless of severity, Lebwohl said. In those cases, clinicians continue and optimize topicals as far as possible. He described the threshold decision as usually straightforward, while allowing patient preference to remain part of it.

How do itch and access shape drug selection?

Lebwohl characterized nemolizumab (Nemluvio; Galderma) as providing rapid itch relief. He often uses it when itching is the patient’s main problem, reflecting his clinical judgment rather than a comparative efficacy result in the discussion.

Dupilumab (Dupixent; Sanofi and Regeneron) is the agent Lebwohl prescribes most among children aged 2 to 12. Copays for some drugs can be exorbitant for Medicare patients, he said, while coverage for dupilumab and nemolizumab is usually fairly easy to obtain. He also said those two drugs are overwhelmingly prescribed in this population.

What does the dupilumab safety record show?

Lebwohl said dupilumab safety data have held up over more than 10 years of use. He described the evidence base as substantial, with the main clinical-trial finding being conjunctivitis in approximately 10% of patients, or roughly 1 in 10. Increases in infections and other anticipated side effects generally did not occur in trials, he said.

Lebwohl does not usually discuss cutaneous lymphoma with parents or patients. He believes cases reported to date reflect diagnostic error because cutaneous lymphoma can look like atopic dermatitis. In the sequence he described, patients receive dupilumab under a presumptive atopic dermatitis diagnosis, then receive the correct lymphoma diagnosis afterward.

What do the pediatric growth findings show?

Data on bone and growth predated the recent data on preventing the atopic march, Lebwohl said. He said patients with significant disease treated with topical therapy alone fail to grow, although he is unsure whether the disease, steroid absorption or systemic steroids explains that outcome.

“In patients treated with dupilumab, growth is greater than those treated with topical corticosteroids,” Lebwohl said.

Lebwohl said better disease management may explain the difference. Avoiding corticosteroids may also contribute, he said, because corticosteroids can cause premature closure of the epiphyseal plates and result in shorter stature.

What remains to be established?

For children aged 2 to 12, approval age and insurance coverage will keep constraining drug choice, while itch-dominant disease may favor nemolizumab in Lebwohl’s practice. The next question is whether better disease control with dupilumab also produces sustained growth gains in children with substantial atopic dermatitis.