Speaker: Dr Abhishek De 

The guidelines for managing atopic dermatitis in India were updated in 2018 but there have been many changes from 2018 to 2024. Since 2016, many new drugs have been introduced like crisaborole, several biologics and Janus kinase (JAK) inhibitors. The current context of atopic dermatitis treatment in India was shaped by three key therapeutic agents: the topical phosphodiesterase 4 (PDE4) inhibitor Crisaborole; systemic treatments Dupilumab, which had been available in India for the past four to five years; and Abrocitinib, which became widely accessible in the country. This session aimed to provide insights into these therapeutic molecule's efficacy and share the lessons learned from their use over the preceding years, thereby contributing valuable information regarding the current state of atopic dermatitis treatment in India. 

The new topical treatment for mild to moderate atopic dermatitis is crisaborole, a PDE4 inhibitor. The effectiveness of the treatment varied among patients, necessitating careful selection. It was noted that the vehicle of the PDE-4 inhibitors also had therapeutic effects, which explained the variability in effectiveness among different brands of crisaborole. The study, published three to four years before PDE-4 inhibitors were introduced in India, represented the first consensus guidelines on this treatment. Subsequent studies included an initial cohort of 19 patients, revealing significant improvements in Investigator Static Global Assessment (ISGA) scores within 28 days. While the results were somewhat lower than international data, improvements were also noted in pruritic scores. Other markers of atopic dermatitis, such as erythema, exudation, excoriation, induration, papulation, and lichenification, showed marked reductions. The results indicate that crisaborole provided a satisfactory outcome for mild to moderate atopic dermatitis, improving patients' quality of life, although it was not used for severe cases.

The study focused on childhood data and found that many patients achieved a primary endpoint within one month of treatment. The study reported that the treatment was quite safe, with only a slight irritation noted in six out of 19 patients. The European Academy of Dermatology and Venereology (EADV) recently published a randomized controlled trial comparing crisaborole and topical tacrolimus, involving 40 patients divided into two groups. The results indicated no significant differences between the treatments; however, these results were achieved with original innovator brand, other brands did not yield similar results. Biologics, specifically Dupilumab, known as interleukin 4 and 13 inhibitor This biologic works by reducing inflammatory cytokines through th2 pathways involved in atopic dermatitis, marking it as a potential game-changer for this condition international data demonstrated favorable outcomes in treating severe atopic dermatitis. Initial findings indicated that approximately 50% of patients experienced at least a 75% improvement in their symptoms. Long-term studies included nearly 4.5 years of international data, consistently showcasing positive results. In conclusion, the study highlighted the potential of Dupilumab as a transformative treatment for atopic dermatitis, presenting itself as a promising option for managing severe cases, supported by a 5-year international dataset demonstrating favorable outcomes.

A study involving 25 patients in Southeast Asia focused on determining the efficacy of Dupilumab. The findings indicated that Dupilumab was effective and a life-changing treatment for many individuals. The data revealed that conjunctivitis was the only reported adverse effect, which was easily managed by eye drops. However, after 4-5 weeks, eczema subsided but some patients developed facial erythema, subsequently identified as Dupilumab-induced facial redness. In response, some individuals in South Korea proposed the use of itraconazole for the management of this condition. Long-term itraconazole treatment was administered, resulting in a decrease in both redness and eczema over approximately three months. The condition is widely recognized. The study has since been published and accepted for dissemination in the scientific community.

The Abrocitinib is a small molecule that is effective in treating inflammation, itch and barrier dysfunction in atopic dermatitis. The JAK inhibitors are life-changing; however, caution must be exercised when selecting the appropriate JAK inhibitor. JAK1 inhibitors had demonstrated promising results in addressing these issues and had a wealth of data to support its efficacy. The recent publication on JAK inhibitors in atopic dermatitis received positive responses.

The study explored the use of JAK inhibitors, particularly Abrocitinib, for patients with severe atopic dermatitis. Within one month of treatment, patients exhibited significant improvement. Abrocitinib should be preferred for individuals aged 12 to 60 years of age who require rapid results. Whereas, for patients under 12 and over 60 years of age, especially those on multiple medications, dupilumab was recommended due to its extensive safety data. Concerns about the cost of Abrocitinib led to a possible recommendation of Tofacitinib. Tofacitinib's efficacy in refractory severe dermatitis cases revealed promising results. The overall response was favorable, but caution was advised due to the potential side effects of JAK inhibitors. Tofacitinib was also deemed suitable for younger children, highlighting its versatility in treatment options. 

33rd European Academy of Dermatology and Venereology Congress, 25-28 September 2024, Amsterdam